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

Unpacking food environment policy landscapes for healthier diets in "emerging" countries: the case of Viet Nam

Objective

Food systems and food environments are evolving rapidly in Viet Nam, concurrently with significant shifts in dietary patterns and health outcomes. This study aims to identify critical gaps in the national regulatory framework governing food environment in Viet Nam and to propose actionable recommendations to overcome these gaps.

Results

Using the Food Environment Policy Index from the INFORMAS network, we mobilized a transdisciplinary panel of 18 experts to co-analyze and assess policy evidence, as well as co-develop policy recommendations. The assessment, encompassing 35 indicators across six food environment domains, revealed substantial gaps: 74% of indicators scored low or very low, while only 26% scored medium or high. Key gaps were identified in food composition standards, marketing, labeling, and financial incentives. Recommendations from the experts focused on strengthening food composition standards, enhancing consumer education, and fostering inter-sectoral policy integration.

Implications

This study provides a comprehensive evaluation of Viet Nam's food environment policies and offers actionable recommendations to foster food environments conducive of healthier diets. Drawing on Viet Nam as a case study representative of challenges in other low- and middle-income countries, our findings highlight the importance of strong political commitment to prioritize public health over industry interests in order to create healthier, more equitable food environments and food systems.

Community-level dietary intake of sodium, potassium, and sodium-to-potassium ratio as a global public health problem: a systematic review and meta-analysis

Background

Widespread adoption of a westernized diet represents a major lifestyle change characterized by substantially higher sodium consumption and lower potassium intake, which is related to cardiovascular morbidity.

Methods

We performed a systematic review and meta-analysis over published studies in accordance with quantifying the dietary intake of sodium and potassium of the universal population across the world. The PubMed, EMBASE, Cochrane Library, and Google Scholar databases were used to find research that pronounced 24-hour urinary sodium or potassium excretion (reference period: 2014-2021). The effect size was estimated using the fixed-effect model; sub-group analysis become accomplished to determine urinary sodium and potassium excretion disaggregated by geographical location. Publication bias became evaluated the usage of graphical funnel plot. Data analysis was performed using STATA 16.

Results

Forty-three studies (n= 62,940) qualified the selection criteria. The mean urinary excretion of sodium and potassium was 156.73 mmol/24h [95% confidence interval (CI), 148.98-164.47] and 48.89 mmol/24 h (95% CI, 43.61-54.17), respectively; the mean urinary sodium/potassium ratio was 3.68 (95% CI, 2.96-4.40).

Conclusions

This updated systematic review highlights excessively high dietary intake of sodium and low intake of potassium at the community level in most parts of the world. The urinary Na/K ratio exceeded the level recommended by the WHO guidelines.

Effect of Salt Reduction Interventions in Lowering Blood Pressure and Salt Intake in Zhejiang Province, China, 2017-2021: A Randomized Controlled Trial

BACKGROUND

Addressing high-salt diets in China through interventions can significantly reduce blood pressure (BP) and the associated health risks.

OBJECTIVE

This study aims to evaluate the effectiveness of a comprehensive salt reduction intervention implemented across counties in Zhejiang Province, focusing on system establishment, extensive publicity, and targeted population interventions.

METHODS

The Salt Reduction and Hypertension Prevention Project was initiated in Zhejiang Province. Cross-sectional surveys were conducted before the intervention and after. The research commenced in 2017 with a baseline survey involving 7512 participants from five counties. Four counties were randomly selected for the intervention, implementing a multifaceted salt reduction strategy, while one county served as a reference without any intervention. The primary outcomes measured were changes in BP and 24 h urinary sodium and potassium excretion.

RESULTS

Following the intervention, 24 h urinary potassium excretion experienced a significant increase, rising from 1441.3 (SD 681.9) to 1676.9 (SD 931.4) mg per day, p < 0.001. Utilizing a linear mixed-effects model, the adjusted net difference in urinary sodium changes was calculated to be 394.1 mg per day (95% CI, 133.2 to 655.0) (p = 0.003). There was a notable reduction in systolic blood pressure (SBP) from 131.2 (SD 19.2) to 129.8 mmHg (SD 18.0), and diastolic blood pressure (DBP) also decreased from 80.8 (SD 10.8) to 78.9 mmHg (SD 10.2), p < 0.001. The adjusted net differences for SBP and DBP between the intervention and reference groups were 1.3 (95%CI, 0.5 to 2.1) and 1.4 mmHg (95%CI, 0.9 to 2.0), respectively, p < 0.001.

CONCLUSIONS

The findings indicate that a multi-sectoral approach, combined with extensive public awareness initiatives and precisely targeted interventions, can significantly increase urinary potassium excretion and reduce sodium and blood pressure.

Dietary Salt-Related Knowledge, Attitudes, and Behaviors of New Zealand Adults Aged 18-65 Years

OBJECTIVE

To explore dietary salt-related knowledge, attitudes, and behaviors of New Zealand (NZ) adults aged 18-65 years and assess differences by demographic subgroups.

DESIGN

Cross-sectional online survey conducted between June 1, 2018 and August 31, 2018.

SETTING

Participants were recruited in shopping malls, via social media, and a market research panel.

PARTICIPANTS

English-speaking adults residing in NZ.

VARIABLES MEASURED

An amended version of The Pan American and World Health Organization Knowledge, Attitudes, and Behaviors standardized survey tool was used. Demographic data (age, sex, ethnicity, and educational attainment) were also collected.

ANALYSIS

Descriptive statistics reported. Chi-square test for independence to assess differences by demographics.

RESULTS

The survey was completed by 1,131 adults (mean age 36 ± 15 years; n = 876 [78%] female; n = 661 [78%] NZ European/other; n = 210 [19%] Asian; n =164 [15%] Māori). In addition, 865 participants (83%) knew the primary dietary source of salt; 406 (40%) knew the recommended salt intake; 946 (95%) believed food manufacturers are responsible for sodium reduction; 563 (55%) supported government regulations; and 259 (26%) used food labels. Females and NZ European/other participants reported more favorable salt-reducing behaviors, such as avoiding fast-food and packaged, ready-to-eat foods (P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Improving salt-related knowledge, attitudes, and behaviors in NZ is particularly important for men, underserved populations, and adults aged 45-65 years. A multicomponent, national NZ salt reduction program based on research addressing engagement and effectiveness for at-risk groups is warranted.

The global magnitude and temporal trend of hypertensive heart disease burden attributable to high sodium intake from 1990 to 2021

BACKGROUND

The relationship between high sodium intake (HSI) and hypertensive heart disease (HHD) has been confirmed. However, notable regional disparities exist in implementing effective measures to control sodium intake. This study was carried out to estimate the spatiotemporal trends in the burden of HHD attributable to HSI.

METHODS

Data obtained from the Global Burden of Disease Study 2021 were analyzed, considering factors such as age, gender, year, and region. Joinpoint regression analysis was applied to investigate the temporal trends in the HHD burden resulting from HSI over the past 32 years.

RESULTS

From 1990 to 2021, the global cases of HHD increased significantly annually. The age-standardized prevalence rates showed a slow gradual increase. However, both the age-standardized death and disability-adjusted life-year (DALY) rates decreased. Specifically, HSI was responsible for 29.2% of total HHD deaths and 30.4% of total DALYs in 1990 but only 22.8% of total HHD deaths and 23.4% of total DALYs in 2021. A greater burden from HSI exposure was observed among men, older adults and people living in middle and low sociodemographic index (SDI) countries and regions. Moreover, over the 32-year period, Guam and Colombia demonstrated the highest reduction in age-standardized death and DALY rates, respectively.

CONCLUSION

Globally, the age-standardized burden of HHD due to HSI has demonstrated a decline. Although some areas have effectively managed this issue, it remains a challenge in specific areas. Hence, it is crucial to examine and implement the strategies adopted by successful nations to further mitigate this burden.

Insights into the salt levels in bread offers in Slovenia: trends and differences

Objective

Bakery products are considered as one of main dietary sources of sodium/salt in Slovenia. Our main objective was to assess the salt content in bread in Slovenia, focusing into different bread categories and sales channels. The data collected in 2022 was compared with year 2012.

Methods

A follow-up study on salt content of bread sold in Slovenia was conducted. Bread samples were purchased in large retail shops and smaller bakeries across 11 statistical regions of Slovenia. Sodium content was determined by inductively coupled plasma mass spectrometry; salt content was calculated by multiplying sodium content with 2.54, assuming all sodium corresponds to sodium chloride.

Results

In 2022, 178 bread samples were purchased and analyzed. Weighted mean salt content in bread was 1.35 (95% CI 1.28-1.42) g/100 g in 2012, and 1.26 (95% CI 1.22-1.29) g/100 g in 2022, showing a 7% decrease. Notable differences in the salt content were observed between various bread subcategories and retail environments. In addition, a significant difference was observed between white wheat bread sold in large retail shops and smaller bakeries, where a higher salt content was observed.

Conclusion

While study results show small decrease in the salt content in bread in Slovenia in last decade, the salt reduction targets set by the WHO have not been met. Additional efforts are needed to stimulate bread reformulation with reducing salt content.

Ethnic differences in knowledge, attitudes, and practices related to dietary salt intake and association with hypertension in Malaysia: a multi-centre cross-sectional study

The association between high salt intake and elevated blood pressure levels has been well-documented. However, studies on how effectively this knowledge translates into actionable practices, particularly across different ethnic groups, remain limited. This study aimed to evaluate the knowledge, attitudes, and practices (KAP) towards dietary salt intake across ethnicities and determine its association with hypertension. 5128 Malaysian adults recruited from a national blood pressure screening study completed questionnaires on demographics, and KAP related to dietary salt intake. There were 57.4% Malay, 23.5% Chinese, 10.4% Indian, and 8.7% individuals of other ethnic groups. Overall, more than 90% of the participants knew that a high salt intake causes serious health problems, but only around one-third knew the relationship between high salt intake and strokes and heart failure. Participants of different ethnic groups displayed significant differences in the KAP domains, where Indians generally exhibited better knowledge, attitudes, and reported better practices such as reading salt labels and using spices. Those who were unaware of the difference between salt and sodium and who reported not reading salt labels had higher odds of having elevated blood pressure. These findings demonstrate that while there is a suboptimal translation of salt knowledge into practice in Malaysia, with significant differences in KAP observed between ethnic groups, the potential of improving health outcomes by improving the clarity and awareness of salt labels is substantial. Tailored education promoting salt-label reading, minimizing processed foods intake and discretionary salt use should be ethnic-specific to better curb this escalating hypertension epidemic.

Estimated health effect, cost, and cost-effectiveness of mandating sodium benchmarks in Australia's packaged foods: a modelling study

BACKGROUND

Excess dietary sodium is a leading cause of death and disability globally. Because packaged foods are a major source of sodium in many countries, including Australia, mandatory limits for sodium might improve population health. We aimed to estimate the long-term health and economic effect of mandating such thresholds in Australia.

METHODS

We used a multiple cohort, proportional, multistate, life table model to simulate the effect of mandating either the WHO global sodium benchmarks or the currently non-mandatory Australian Healthy Food Partnership (HFP) sodium targets. We compared maintaining the current sodium intake status quo with intervention scenarios, using nationally representative data on dietary intake, sodium in packaged foods, and food sales volume. Blood pressure and disease burden data were obtained from the Global Burden of Diseases, Injuries, and Risk Factors Study. The effect of sodium reduction on blood pressure and disease risk was modelled on the basis of meta-analyses of randomised trials and cohort studies. Intervention and health-care costs were used to calculate the incremental cost per health-adjusted life-year (HALY) gained. Costs and HALYs were discounted annually at 3%.

FINDINGS

Compared with the status quo intervention, mandating the WHO benchmarks could be cost saving over the first 10 years (AUD$223 [95% uncertainty interval 82-433] million saved), with 2743 (1677-3976) cardiovascular disease deaths and 43 971 (26 892-63 748) incident cardiovascular disease events averted, and 11 174 (6800-16 205) HALYs gained. Over the population's lifetime, the intervention was cost effective (100·0% probability). Mandating the HFP sodium targets was also estimated to be cost effective (100·0% probability), but with 29% of the health benefits compared with the WHO benchmarks.

INTERPRETATION

Our modelling study supports mandating sodium thresholds for packaged foods as a cost-effective strategy to prevent death and disease in Australia. Although making Australia's voluntary reformulation targets mandatory might save thousands of lives, mandating the WHO global benchmarks could yield substantially greater health gains.

FUNDING

None.

Advances in Research on the Improvement of Low-Salt Meat Product Through Ultrasound Technology: Quality, Myofibrillar Proteins, and Gelation Properties

The high sodium content in meat products poses health risks to consumers and does not align with modern green and healthy living standards. Current strategies for directly reducing the sodium content in meat products are limited by their negative impact on the sensory or quality attributes of the products. In recent years, there has been great interest in applying ultrasound technology to reduce sodium content. This paper discusses the advantages and disadvantages of current mainstream strategies for reducing the sodium content in meat products, as well as the potential mechanisms by which ultrasound-assisted marination improves the quality of low-salt meat products. The main findings indicate that ultrasound, through its cavitation and mechanical effects, facilitates the transition of proteins from stable insoluble aggregates to stable soluble complexes, exposing more hydrophilic groups and, thus, enhancing protein solubility. At the same time, ultrasound promotes a greater number of proteins to participate in the formation of interfacial layers, thereby increasing emulsifying activity. Furthermore, ultrasound treatment promotes the interaction between proteins and water, leading to partial unfolding of protein chains, which allows polar residues to more readily capture water in the gel, thereby improving the water-holding capacity of the gel. These effects will contribute to the formation of high-quality low-salt meat products. However, variations in the frequency, intensity, and duration of ultrasound treatment can lead to differing effects on the quality improvement of low-salt meat products.

Analysis of factors associated with public attitudes towards salt reduction: a multicountry cross-sectional survey

OBJECTIVE

This paper provides an in-depth examination of public attitudes towards salt reduction across seven culturally diverse countries: the USA, the UK, France, Japan, Indonesia, Thailand, and Brazil.

DESIGN

Cross-sectional regression analysis with questionnaire data.

SETTING

An analysis of questionnaire study in seven countries.

PARTICIPANTS

The study's questionnaire collected responses from 7090 participants across seven countries with the mean age of respondents being 46.06 years (SD 16.96). The gender distribution encompassed 3473 men (49.12%), 3582 women (50.66%), 24 non-binary individuals (0.34%) and 11 who identified as 'other' (0.16%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Attitudes toward sodium reduction were measured on a seven-point Likert scale.

RESULTS

Regression analysis revealed significant associations between attitudes towards sodium reduction and various factors across countries. Gender was a significant factor in France, with women showing less awareness than men (coefficient -0.123, 95% CI -0.237 to -0.008). Age was a significant factor in Japan and Thailand, with older generations exhibiting stronger awareness. Occupation was a significant factor in France (grocery, 0.678, 0.229 to 1.127) and Japan (food service, 0.792, 0.300 to 1.283). In France (0.090, 0.033 to 0.146) and Brazil (0.092, 0.040 to 0.144), attitudes towards reducing sugar intake were positively associated with sodium reduction attitudes. Government interventions showed varying impacts, with positive associations in Thailand (0.004, 0.001 to 0.008) and negative associations in France (-0.003 -0.005 to -0.000).

CONCLUSION

Our study reveals a complex array of factors shaping attitudes towards sodium reduction across seven countries. These findings support the need for nuanced, country-specific approaches in formulating sodium reduction strategies. Future research should validate these findings, explore further determinants and understand how attitudes translate into dietary behaviours.

The Impact of Non-Fiscal Mandatory and Voluntary Policies and Interventions on the Reformulation of Food and Beverage Products: A Systematic Review

Background/Objectives: Low quality diets are a risk factor for non-communicable diseases; therefore, improving diet quality is a public health and policy priority in the UK and elsewhere. Reformulating food/beverage products to make them healthier may be an effective approach. Evidence suggests that fiscal interventions, notably taxes/levies on soft drinks, can lead to reformulation but the evidence for voluntary or mandated non-fiscal interventions is less clear. We aimed to review and synthesise contemporary evidence to determine whether non-fiscal policies/interventions result in the reformulation of food/beverage products Methods: In April 2023, we systematically searched ten international academic and nine grey literature databases. We included real-world study designs, all nutrients, in- and out-of-home sectors, and studies published from 2013, to ensure policy relevancy. We excluded modelling studies. Using the Synthesis Without Meta-Analysis method we conducted vote counting of studies based on the direction of effect and narrative synthesis by intervention type. Risk of bias was assessed using a tool developed by the EPPI-Centre and quality was assessed using GRADE. Results: We included 77 real-world studies from 19 countries, reporting 100 non-fiscal policies/interventions. Most commonly, these were reduction targets (n = 44), front-of-pack labels (n = 23), and advertising standards (n = 9). Most interventions were voluntary (n = 67), compared to mandatory (n = 33), and focused on the in-home sector (n = 63). The vote counting results showed non-fiscal policies/interventions overall led to improvements in reformulation in 60/63 studies with a valid direction of effect (95%, 95% CI 0.869, 0.984, p < 0.001). Mandatory implementations were more successful than voluntary implementations with 15/15 showing an improvement (100%, 95% CI 0.796, 1], p < 0.001), compared 40/43 showing an improvement (93%, 95% CI 0.814, 0.976, p < 0.001). Most of the studies were of low quality, due to the observational nature of the studies. Sodium was the most commonly targeted nutrient (n = 56) and was found to be reformulated in most studies. Causation is difficult to establish from real-world studies, but evidence suggests that regulatory and multi-component strategies may be effective at driving reformulation. Conclusions: Non-fiscal policies/interventions can play an important role in driving reformulation, alongside fiscal measures. This work was funded by the National Institute for Health and Care Research PRP-PRU-02-15-Healthy Weight and registered on Open Science Framework.

Effect of educational intervention based on the theory of planned behavior (TPB) on amount of salt intake in pregnant women with PreHypertension

BACKGROUND

Prehypertension is one of the common disorders during pregnancy. Reducing salt intake is among the best cost-effective interventions to reduce the risk of hypertension. The present study aimed to explore the effect of an educational intervention based on the Theory of Planned Behavior (TPB) on amount of salt consumed by prehypertensive pregnant women.

METHODS

The present quasi-experimental study was conducted in 2022 on 61 prehypertensive pregnant women visiting the Comprehensive Health Services Centers in Birjand, Iran. Pregnant women were selected through a convenience sampling method and randomly assigned to intervention and control groups. A blood pressure test and a 24-hour urine test were taken in 3 stages (before, immediately after, and one month after the intervention). A reliable and valid questionnaire based on the TPB was used to measure the cognitive variables. The intervention program included three training sessions based on the TPB held on an online platform (WhatsApp social network). Data were analyzed using repeated measures ANOVA and longitudinal marginal model with the GEE approach in SPSS19. The significance level for all statistical tests was set at p < 0 0.05.

RESULTS

After intervention, the mean score of perceived behavioral control (p = 0.02), intention (p = 0.004), and salt consumption behavior (p = 0.03) increased significantly in the intervention group, and the mean score of systolic blood pressure (p < 0.001) and diastolic blood pressure (P < 0.01) decreased significantly in this group. In the control group, a statistically significant difference was observed in the systolic and diastolic blood pressure of the subjects (p < 0.01). However, the score of attitude, subjective norms, perceived behavioral control, intention, salt consumption behavior and the daily salt intake did not show a statistically significant difference over time (P < 0.05).

CONCLUSION

The present findings showed that the perceived behavioral control, intention, behavior, systolic and diastolic blood pressure can be modifiable variables to improve the amount of salt consumed by pre-hypertensive pregnant women. Therefore, we recommend that the present model be used to develop interventions to improve health indicators in pregnant women as a highly susceptible group in society.

Food insecurity and the consumption of plant-centered meals and high sodium foods among students at three large state universities

Objective: To examine the associations between food insecurity and plant-centered meal consumption and other sodium-related dietary behaviors among university students. Methods: A web-based survey of students at three California state universities was conducted between August 2018 to May 2019. Multivariable logistic regressions examined the associations between food insecurity and four sodium-related dietary behaviors. Interaction terms were introduced to assess if race/ethnicity moderated these associations. Results: High food insecurity was associated with increased odds of reporting 'likely to order' plant-centered meals (AOR = 1.55, 95% CI = 1.16-2.05). Moderate food insecurity was associated with increased odds of frequently eating processed foods (AOR = 1.40, 95% CI = 1.13-1.74). No moderation effects were found for race/ethnicity. Conclusions: University students with high food insecurity appeared receptive to ordering plant-centered meals, whereas those with moderate food insecurity consumed more processed foods. State universities should encourage and offer more low-sodium, plant-centered meal options in their food venues, on- and off-campus, to promote student health.

Development of a Nutrient Profile Model for Dishes in Japan Version 1.0: A New Step towards Addressing Public Health Nutrition Challenges

To address the rising incidence of non-communicable diseases (NCDs) and promote healthier eating habits, Japan requires a culturally tailored Nutrient Profile Model. This study aimed to develop a Nutrient Profile Model for Dishes in Japan version 1.0 (NPM-DJ (1.0)) that corresponds to the nutritional issues and food culture in Japan. The aim of the NPM-DJ (1.0) was to promote the health of the general population, and to prevent the increase in NCDs in Japan. The NPM-DJ (1.0) categorizes dishes into staples, sides, mains, mixed dishes, and mixed dishes with staples. The model evaluates dishes based on energy, saturated fats, sugars, and sodium as restricted nutrients, while considering protein, dietary fiber, and the weight of certain food groups as recommended nutrients. The distribution of the overall score for each dish category was analyzed and a rating algorithm was created. The baseline, modification points, and final scores were significantly lower for side dishes than for staple dishes. In contrast, the baseline points and final scores were significantly higher for mixed dishes with staple. The model effectively differentiated nutritional profiles across five dishes categories, which may promote healthier dish reformulation by food businesses operators and encourage consumers to select healthier dishes.

Iodine and selenium: Dietary sources and nutritional status of the population of the Kurdistan Region in Northern Iraq

AIM

The primary aim of this study was to determine the selenium (Se) and iodine (I) food concentrations and dietary intake of the population living in the Kurdish controlled region of northern Iraq. We also assessed the extent to which iodised salt contributes to dietary iodine intake.

METHODOLOGY

Foods and samples of salt and drinking water were analysed, including 300 crops samples from 40 local farms. The results, supplemented by food composition data, were used to assess dietary Se and I intake for 410 volunteers using a semi-quantitative food questionnaire. To directly investigate the nutritional status of individuals, urine samples were also collected from participants.

RESULTS

Selenium intake was mainly supplied by protein and cereal sources. Calculated median dietary intake of Se was 62.7 µg d-1 (mean = 66.3 µg d-1) with c. 72 % of participants meeting or exceeding dietary reference intake recommendations for age. Median dietary intake of I, excluding salt consumption, was 94.6 µg d-1 (mean 100.2 µg d-1), increasing to 607.2 µg d-1 when salt (of which >90 % was iodized) was included. Salt intake was estimated to be c.13.5 g d-1 (5400 mg Na d-1) which greatly exceeds WHO recommended intake (< 2000 mg d-1 of Na). Urine iodine concentrations indicated that 98 % of school aged children had excessive iodine intake (≥300 µg L-1) and 80-90 % of all study participants had above average or excessive iodine intake (≥200 µg L-1).

CONCLUSIONS

Poultry and rice are the main sources of dietary Se to this population but around a third of children receive an inadequate Se intake. Fresh fruit and vegetables are the main sources of dietary I, but consumption of local foods cannot supply adequate I without iodised salt supplementation. Consumption of iodized salt well above recommended amounts is supplying this population with substantial iodine intake. Interventions to reduce salt intake would help to limit excessive iodine intake whilst also reducing cardio-vascular risks from Na consumption.

Assessment of Salt, Potassium, and Iodine Intake in the Croatian Adult Population Using 24 h Urinary Collection: The EH-UH 2 Study

Cardiovascular diseases, which are the leading cause of death in Croatia, are linked to the high prevalence of hypertension. Both are associated with high salt intake, which was determined almost two decades ago when Croatian Action on Salt and Health (CRASH) was launched. The main objective of the present study was to evaluate salt, potassium, and iodine intake using a single 24 h urine sample in a random sample of the adult Croatian population and to analyse trends in salt consumption after the CRASH was intensively started.

METHODS

In this study, we analysed data on 1067 adult participants (mean age 57.12 (SD 13.9), men 35%).

RESULTS

Mean salt and potassium intakes were 8.6 g/day (IQR 6.2-11.2) and 2.8 g/day (IQR 2.1-3.5), respectively, with a sodium-to-potassium ratio of 2.6 (IQR 1.8-3.3). We detected a decrease of 17.6% (2 g/day less) in salt consumption compared with our previous salt-mapping study. However, only 13.7% and 8.9% met the WHO salt and potassium recommended targets of 5 g/day and 3.5 g/day, respectively. Salt intake was higher, and potassium ingestion was lower, in rural vs. urban regions and in continental vs. Mediterranean parts of Croatia. Moderate to severe iodine insufficiency was determined in only 3% of the adult participants.

CONCLUSION

In the last fifteen years, salt consumption has been significantly reduced in the Croatian adult population because of the intensive and broad CRASH program. However, salt intake is still too high, and potassium ingestion is too low. Salt reduction programs are the most cost-effective methods of cardiovascular disease prevention and merit greater consideration by the government and health policy makers.

Single nucleotide polymorphism-based biomarker in primary hypertension

Primary hypertension is a multiplex and multifactorial disease influenced by various strong components including genetics. Extensive research such as Genome-wide association studies and candidate gene studies have revealed various single nucleotide polymorphisms (SNPs) related to hypertension, providing insights into the genetic basis of the condition. This review summarizes the current status of SNP research in primary hypertension, including examples of hypertension-related SNPs, their location, function, and frequency in different populations. The potential clinical implications of SNP research for primary hypertension management are also discussed, including disease risk prediction, personalized medicine, mechanistic understanding, and lifestyle modifications. Furthermore, this review highlights emerging technologies and methodologies that have the potential to revolutionize the vast understanding of the basis of genetics in primary hypertension. Gene editing holds the potential to target and correct any kind of genetic mutations that contribute to the development of hypertension or modify genes involved in blood pressure regulation to prevent or treat the condition. Advances in computational biology and machine learning enable researchers to analyze large datasets and identify complex genetic interactions contributing to hypertension risk. In conclusion, SNP research in primary hypertension is rapidly evolving with emerging technologies and methodologies that have the potential to transform the knowledge about genetic basis related to the condition. These advances hold promise for personalized prevention and treatment strategies tailored to an individual's genetic profile ultimately improving patient outcomes and reducing healthcare costs.

Switches in food and beverage product purchases can reduce greenhouse gas emissions in Australia

Switching between similar food and beverage products may reduce greenhouse gas emissions (GHGe). Here, using consumer data linked to 23,550 product-specific GHGe values, we estimated annual GHGe attributable to product purchases consumed at home in Australia and calculated reductions from specific switches. Potential changes to mean Health Star Rating, mean energy density and the proportion of ultraprocessed foods purchased were assessed. Approximately 31 million tonnes of GHGe were attributable to products consumed at home in 2019, the three highest contributors of GHGe being 'meat and meat products' (49%), 'dairy' (17%) and 'non-alcoholic beverages' (16%). Switching higher-emission products for 'very similar' lower-emission products could reduce total emissions by 26%. Switches to 'less similar' lower-emission products could lead to a 71% reduction. Switches had little impact on the average Health Star Rating, energy density of purchases and proportion of ultraprocessed foods purchased. Directing manufacturing and marketing towards lower-environmental-impact products and signposting such options to consumers are key.

Development of a Culinary Intervention (Cooking Class) for Salt Reduction in Japanese Home Cooking: Strategies and Assessment

Introduction

Culinary interventions (cooking classes) are a potential educational tool for salt reduction in the home diet, but their content has never been reported in detail. This study aimed to develop a cooking class for salt reduction, describe its rationale and structure so that other parties could replicate it, and preliminarily assess its impact on salt intake.

Methods

A multidisciplinary research team developed a cooking class package to reduce salt content in the Japanese home diet. The package comprised its developmental policy, teaching methodology, a menu and recipes, and an implementation manual and aimed to allow third parties to replicate and modify the content. The team took the following step-by-step developmental approach. First, traditional home meals were modeled to create strategies contributing to a target of 2 g salt/meal. Then, educational topics were developed through these strategies, and finally, a dietitian produced menus and prepared documents for the class. The impact of the cooking class was assessed in a nonrandomized study of community residents. The outcome was differences in urinary salt excretion before and after the intervention. General linear models were used to account for the possible confounders.

Results

The authors assumed 4-7 g salt/meal from analyzing typical Japanese home diets and developed 3 strategies: (1) restricting salt content in the main dish, (2) maintaining good tastes without salty dishes, and (3) balancing nutrition with low-salt dishes. On the basis of these strategies, the authors selected a total of 5 educational topics that participants could learn and apply at home: 1a, a simple and reliable technique to limit salt in a serving; 2a, excluding salty dishes; 2b, staple foods with notable flavor and aroma; 3a, flavoring without salt in side dishes; and 3b, ingredients that should be used intentionally. The team dietitian translated these educational topics into a menu and recipes for hands-on training and prepared a manual for conducting the class. The class developed using this approach was successfully overseen by a dietitian outside the research team. In the validation study, the intervention group (n=52) showed a greater decrease in urinary salt excretion than the control group (n=46), with an adjusted difference of -1.38 g (p=0.001).

Conclusions

The authors developed a cooking class package for salt reduction so that third parties could replicate and modify the class. The significant salt reduction noted in this study warrants further studies to apply this cooking class to other populations.

Croatian Action on Salt and Health (CRASH): On the Road to Success-Less Salt, More Health

The World Health Organization recommends adjusting salt intake as a part of the nine global targets to reduce premature mortality from non-communicable chronic diseases as a priority and the most cost-effective intervention. In 2006, the main aim of the Croatian Action on Salt and Health was to decrease salt intake by 16% because of its critical intake and consequences on human health. We have organized educative activities to increase awareness on salt harmfulness, define food categories of prime interest, collaborate with industries and determine salt intake (24 h urine sodium excretion). It was determined that the proportion of salt in ready-to-eat baked bread should not exceed 1.4%. In the period 2014-2022, salt in semi-white bread was reduced by 14%, 22% in bakery and 25% in the largest meat industry. Awareness of the harmfulness of salt on health increased from 65.3% in 2008 to 96.9% in 2023 and salt intake was reduced by 15.9-1.8 g/day (22.8% men, 11.7% women). In the last 18 years, a significant decrease in salt intake was achieved in Croatia, awareness of its harmfulness increased, collaboration with the food industry was established and regulatory documents were launched. However, salt intake is still very high, underlying the need for continuation of efforts and even stronger activities.

Can sodium and potassium measured in timed voids be used as reference instruments for validating self-report instruments? Results from a urine calibration study

BACKGROUND

Sodium and potassium measured in 24-h urine collections are often used as reference measurements to validate self-reported dietary intake instruments.

OBJECTIVES

To evaluate whether collection and analysis of a limited number of urine voids at specified times during the day ("timed voids") can provide alternative reference measurements, and to identify their optimal number and timing.

METHODS

We used data from a urine calibration study among 441 adults aged 18-39 y. Participants collected each urine void in a separate container for 24 h and recorded the collection time. For the same day, they reported dietary intake using a 24-h recall. Urinary sodium and potassium were analyzed in a 24-h composite sample and in 4 timed voids (morning, afternoon, evening, and overnight). Linear regression models were used to develop equations predicting log-transformed 24-h urinary sodium or potassium levels using each of the 4 single timed voids, 6 pairs, and 4 triples. The equations also included age, sex, race, BMI (kg/m2), and log creatinine. Optimal combinations minimizing the mean squared prediction error were selected, and the observed and predicted 24-h levels were then used as reference measures to estimate the group bias and attenuation factors of the 24-h dietary recall. These estimates were compared.

RESULTS

Optimal combinations found were as follows: single voids-evening; paired voids-afternoon + overnight (sodium) and morning + evening (potassium); and triple voids-morning + evening + overnight (sodium) and morning + afternoon + evening (potassium). Predicted 24-h urinary levels estimated 24-h recall group biases and attenuation factors without apparent bias, but with less precision than observed 24-h urinary levels. To recover lost precision, it was estimated that sample sizes need to be increased by ∼2.6-2.7 times for a single void, 1.7-2.1 times for paired voids, and 1.5-1.6 times for triple voids.

CONCLUSIONS

Our results provide the basis for further development of new reference biomarkers based on timed voids.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov as NCT01631240.

Manufacture of Low-Na White Soft Brined Cheese: Effect of NaCl Substitution with a Combination of Na-K Salts on Proximate Composition, Mineral Content, Microstructure, and Sensory Acceptance

All over the world, especially in Western societies, table salt intake that is inordinately higher than the acceptable level has been observed. An excess of Na in the human diet, mostly from processed foods, is becoming the "number one killer", leading to increased blood pressure. Therefore, the food industry is faced with a need to reduce Na in human nutrition in an effort to raise public health protection to a higher level. In this study, a commercially available combination of Na/K salts (COMB) at different concentrations was used as a NaCl substitute in the production of a modified, healthier, Na-reduced cheese. Samples of the modified low-Na white soft-brined cheese (WSBC) were produced by adding four different concentrations of COMB to production lots PL-1 to PL-4, and the control (CON) samples were prepared by salting with the usual, non-reduced concentration of NaCl. The effects of NaCl replacement on the physical-chemical parameters, major- and micro-elements, and microstructural and sensory properties of the WSBC were investigated. The obtained results indicated that there was no significant influence on the ash content, pH, and aw. The Na and K levels differed among treatments (p < 0.001). The lowest Na level in this study was recorded in PL-4 (only COMB was added) and was 334.80 ± 24.60 mg/100 g. According to the Na content, WSBC PL4 can be labeled with the nutrient claim "reduced amount of Na". A significant difference (p < 0.05) was noticed in overall acceptance between the CON and PL-4, with no statistically significant difference found amongst other WSBC production lots. The replacement of NaCl resulted in a slightly greater firmness of the WSBC. The results confirm the possibility of producing low-Na WSBC when optimal amounts of a suitable mineral salt are used as a substitute for NaCl, thus reducing the risk of high Na intake in the human body through the consumption of evaluated cheese.

Trend and projection of non-communicable diseases risk factors in Iran from 2001 to 2030

This study aims to investigate the trends and project the major risk factors of Non-communicable Diseases (NCDs) in Iran. We obtained the trend of prevalence of main risk factors related to NCDs in 30 to 70-year-old-individuals. The data were extracted from WHO STEP wise approach to NCDs risk factor surveillance (STEPS) survey. Also,the previous studies conducted at national and subnational levels from 2001 to 2016 were employed. The prevalence of risk factors was projected by 2030 using Bayesian Model Averaging (BMA) and Spatio-temporal model stratified by sex and province. The percent change for the age-standardized prevalence of smoking in men between 2001 and 2016 was calculated to be - 27.0. Also, the corresponding values for the risk factors of diabetes, hypertension, obesity and overweight, physical inactivity (PI), and mean of salt intake were - 26.1, 29.0, 70.0, 96.8, 116.6, and 7.5, respectively. It is predicted that smoking and these risk factors will undergo a change to show values of - 1.26, 38.7, 43.7, 2.36, and 15.3 by 2030, respectively. The corresponding values in women for the time interval of 2001-2016 were - 27.3, 26.3, 82.8, 1.88, 75.2, and 4.2, respectively. Plus, projections indicate that the 2030 variation values are expected to be - 25.0, 16.7, 37.5, 28.7, 26.7, and 10.9 respectively. This study showed that the prevalence of four risk factors of PI, overweight and obesity, hypertension, and diabetes is increasing in Iran. Therefor, it is necessary to carry out effective interventions to adopt a healthy lifestyle and reduce the risk factors.

Knowledge and practices related to salt consumption in China: findings from a national representative cross-sectional survey

There is limited information on the knowledge and practice of salt-reduction in China. The purpose of this study was to describe the status of the knowledge and practice of salt-reduction among the Chinese population from a nationally representative survey stratified according to hypertension status. The association between hypertensive status and salt-reduction knowledge and practice was calculated using multivariate hierarchical logistic regression adjusting for related confounders. The study included 179,834 participants; 51.7% were women, and the mean age was 44 years. The levels of overall salt-reduction knowledge (7.9%) and practice (37.1%) were low. The percentage of the use of salt-control spoons and low-sodium salt was 10.7% and 12.2%. The aging population (≥60 years) had the lowest levels of salt-reduction knowledge (5.7%) than other age groups (P < 0.0001). People living in rural areas (OR = 0.64; 95% CI: 0.51, 0.81) had lower odds of using salt-control spoons. Females (OR = 1.23; 95% CI: 1.10, 1.36) had higher odds of using salt-control spoons. People living in rural areas (OR = 0.48; 95% CI: 0.36, 0.63) had lower odds of using low-sodium salt. Females (OR = 1.26; 95% CI: 1.13, 1.41) and people living in the southern region (OR = 1.43; 95% CI: 1.11, 1.83) had higher odds of using low-sodium salt. Our work highlights the need to promote education related to hypertension, salt-reduction knowledge and methods among the public and the need to strengthen strategies for the popularization of salt-reduction knowledge and practices among males, people living in rural areas, people living in the northern region and the aging population in China.

The Future for the Children of Tomorrow: Avoiding Salt in the First 1000 Days

It is widely known that optimal nutrition in the first 1000 days of life positively impacts the child's development throughout adulthood. In this setting, salt should not be added to complementary feeding. In developed countries, salt intake is generally higher than recommended for children. Excessive salt intake is the major determinant of hypertension and is associated with several cardiovascular outcomes. Therefore, pediatricians have a key role in raising awareness among parents to avoid salt consumption in the first 1000 days of life to ensure better health for their children. Starting from a review of the literature published in PubMed/MedLine regarding the short- and long-term consequences of salt consumption during the first 1000 days of life, our comprehensive review aims to analyze the beneficial effects of avoiding salt at such a vulnerable stage of life as the first 1000 days. Obesity, hypertension, increased salt sensitivity, high sweet drink consumption, increased mortality, and morbidity persisting in adult age represent the principal consequences of a higher salt intake during the first 1000 days of life.

Gastrointestinal tolerance of D-allulose in children: an acute, randomised, double-blind, placebo-controlled, cross-over study

D-Allulose, a low-calorie sugar, provides an attractive alternative to added sugars in food and beverage products. There is however limited data on its gastrointestinal (GI) tolerance, with only two studies in adults, and no studies in children to date. We therefore performed an acute, randomised, double-blind, placebo-controlled, cross over study designed to determine, for the first time, the GI tolerance of 2 doses of D-allulose (2.5 g per 120 ml and 4.3 g per 120 ml) in young children. The primary tolerance endpoint was the difference in the number of participants experiencing at least one stool that met a Type 6 or Type 7 description on the Bristol Stool Chart, within 24 hours after study product intake. Secondary endpoints included the assessment of stool frequency, stool consistency, and the presence of GI symptoms. Only one participant in the low dose group experienced a stool type 6 or 7, while no participants experienced a stool type 6 or 7 in the high dose group. A statistically significant difference in the change in stool frequency compared to placebo in the high dose group (p = 0.044) was found, with no significant difference between the groups for stool consistency and no participants experienced unusual stool frequency. All the encountered adverse events were non-serious, either mild or moderate, and there were no serious adverse events. All in all, D-allulose was tolerated well in children, making this ingredient a good candidate to reformulate commercially produced goods by replacing added sugars with lower caloric content.

Effective policies to promote sugar reduction in soft drinks: lessons from a comparison of six European countries

BACKGROUND

Many countries have sought to incentivise soft drinks manufacturers to reduce sugar in their products as part of efforts to address a growing prevalence of obesity. Are their policies effective?

METHODS

Using a difference-in-differences design, we compared trends in the sugar content of 10 695 new sugar-sweetened beverages (SSB) launched between 2010 and 2019 in six European markets, including the UK and France (taxes designed to incentivise reformulation), the Netherlands (policy based on voluntary agreements to reduce sugar), Germany, Italy and Spain (no national policies).

RESULTS

The announcement in 2016 and adoption in 2018 of the UK tax led to yearly reductions in average sugar content of 17% (95% CI: 15-19%) to 31% (13-48%) between 2016 and 2019, compared to 2015, while the 2018 French tax produced a 6% (95% CI: 5-7%) sugar reduction only in 2018, compared to 2017, shortly after it was redesigned to provide a stronger incentive for reformulation. Voluntary agreements implemented in the Netherlands in 2014 led to an 8% (95% CI: 4-13%) sugar reduction only in 2015, compared to 2013.

CONCLUSION

The analysis supports the conclusions that sugar reductions in new SSBs have been greater in countries that have adopted specific policies to encourage them; a sugar-based tax design encourages more sugar reductions than a volume-based tax design; the tax rate and the amount of the tax reduction from switching to the next lower tier in a sugar-based tax design may be critical to incentivize reformulation.

Population-level salt intake in the WHO European Region in 2022: a systematic review

OBJECTIVE

The WHO recommends that adults consume less than 5 g of salt per day to reduce the risk of CVD. This study aims to examine the average population daily salt intake in the fifty-three Member States of the WHO European Region.

DESIGN

A systematic review was conducted to examine the most up-to-date salt intake data for adults published between 2000 and 2022. Data were obtained from peer-reviewed and grey literature, WHO surveys and studies, as well as from national and global experts.

SETTING

The fifty-three Member States of the WHO European Region.

PARTICIPANTS

People aged 12 years or more.

RESULTS

We identified fifty studies published between 2010 and 2021. Most countries in the WHO European Region (n 52, 98 %) reported salt intake above WHO recommended maximum levels. In almost all countries (n 52, 98 %), men consume more salt than women, ranging between 5·39 and 18·51 g for men and 4·27 and 16·14 g for women. Generally, Western and Northern European countries have the lowest average salt intake, whilst Eastern European and Central Asian countries have the highest average. Forty-two percentage of the fifty-three countries (n 22) measured salt intake using 24 h urinary collection, considered the gold standard method.

CONCLUSIONS

This study found that salt intakes in the WHO European Region are significantly above WHO recommended levels. Most Member States of the Region have conducted some form of population salt intake. However, methodologies to estimate salt intake are highly disparate and underestimations are very likely.

Salt reduction behavior of adults in Anhui province in 2019: a cross-sectional survey of 3,378 participants

Objective

A high-sodium diet is an important risk factor for hypertension in the Chinese population, which can increase the risk of cardiovascular and cerebrovascular diseases. Although a large number of related studies have been carried out in Anhui province, clear, effective salt reduction interventions and policies that can be widely promoted have not yet been formed. This study sought to understand the prevalence and precise measures of salt reduction behavior, the variables affecting salt reduction behavior, and the reasons why salt reduction behavior was not practiced in Anhui Province, China.

Methods

The total number of participants in the study was 3,378. Using a multi-stage stratified cluster random sampling method, residents between the ages of 18 and 69 years in 10 counties and districts were selected from March to October 2019. A survey questionnaire and physical measurements were given to each participant. The influencing factors of residents' salt reduction behavior were examined using a multi-factor unconditional logistic regression analysis. The chi-squared (χ2) test was used to analyze the implementation of salt reduction behaviors among different age groups and gender, the factors influencing the implementation of salt reduction measures, and the reasons for not implementing salt reduction measures.

Results

A history of hypertension was associated with salt reduction strategies (P = 0.014). Patients with hypertension were more likely to adopt salt reduction behaviors than those without hypertension (OR = 1.218, P = 0.040). The influence of eating out on the adoption of salt-reduction measures varied by age group (χ2 = 50.463, P < 0.001) and gender (χ2 = 81.348, P < 0.001).

Conclusion

In summary, residents of the Anhui Province are not very knowledgeable about salt reduction. Age, gender, education level, hypertension, and marital status are the main determinants. Our findings have significant implications for policymakers who want to devise salt reduction strategies.

Changes in the Sodium Content in Branded Foods in the Slovenian Food Supply (2011-2020)

High sodium intake is the leading diet-related risk factor for mortality globally. Many countries have introduced policies to support the reformulation of foods and to reduce sodium intake, mainly on a voluntary basis, but there are limited data available about the long-term efficiency of such measures. Slovenia implemented salt reduction policies for the period of 2010-2020; these policies also included the voluntary reformulation of foods with the lowering of sodium content. This study's aim was to explore the nationally representative branded food datasets collected in the years 2011, 2015, 2017, and 2020 to investigate the changes in the sodium content in prepacked branded foods. The study was conducted with datasets collected from food labels using standard food monitoring studies and included all the major retailers. Differences in market shares were adjusted by sales weighting, which was conducted using the yearly sales data provided by the major retailers. The food categories with a major contribution to the overall sales of sodium in prepacked branded foods were processed meat and derivatives (19.0%), canned vegetables (7.1%), water (6.7%), bread (7.2%), and cheese (6.3%). Considering the available food products, a notable decreasing sodium content trend was observed in biscuits, breakfast cereals, pizza, and spreads. Year-to-year differences were much less expressed after the correction for market share differences, and neutral trends were most frequently highlighted. This indicates that sodium was less frequently reduced in market-leading products. The study results revealed that very limited progress in sodium food reformulation was achieved in the 10-year period, indicating the need for more efficient policy approaches. The study demonstrated the importance of the systematic monitoring of the food supply for the evaluation of food policies.

Less sodium, more potassium, or both: population-wide strategies to prevent hypertension

Hypertension is among the most prevalent medical conditions globally and a major contributor to chronic kidney disease, cardiovascular disease, and death. Prevention through nonpharmacological, population-level interventions is critically needed to halt this worldwide epidemic. However, there are ongoing disagreements as to where public policy efforts should focus. Recently the Salt Substitute and Stroke Study demonstrated the efficacy of substituting table salt with potassium salt to reduce the risk of stroke, major cardiovascular events, and death. However, this sparked debate over whether sodium or potassium should be prioritized in countries where table salt substitution was less feasible. In this commentary, we summarize arguments in favor of either strategy: reduced sodium or increased potassium intake. Moreover, we discuss evidence and policy approaches related to either or combined approaches relevant to cultural context. Ultimately, there is an urgent need for policies that both reduce sodium and increase potassium intake; however, identifying a strategy that fits cultural context will be key to improve population-wide blood pressures.

Sodium content in processed food items in Sweden compared to other countries: a cross-sectional multinational study

Background

Dietary sodium has a dose-response relationship with cardiovascular disease, and sodium intake in Sweden exceeds national and international recommendations. Two thirds of dietary sodium intake comes from processed foods, and adults in Sweden eat more processed foods than any other European country. We hypothesized that sodium content in processed foods is higher in Sweden than in other countries. The aim of this study was to investigate sodium content in processed food items in Sweden, and how it differs from Australia, France, Hong Kong, South Africa, the United Kingdom and the United States.

Methods

Data were collected from retailers by trained research staff using standardized methods. Data were categorized into 10 food categories and compared using Kruskal-Wallis test of ranks. Sodium content in the food items was compared in mg sodium per 100 g of product, based on the nutritional content labels on the packages.

Results

Compared to other countries, Sweden had among the highest sodium content in the "dairy" and "convenience foods" categories, but among the lowest in "cereal and grain products," "seafood and seafood products" and "snack foods" categories. Australia had the overall lowest sodium content, and the US the overall highest. The highest sodium content in most analyzed countries was found in the "meat and meat products" category. The highest median sodium content in any category was found among "sauces, dips, spreads and dressings" in Hong Kong.

Conclusion

The sodium content differed substantially between countries in all food categories, although contrary to our hypothesis, processed foods overall had lower sodium content in Sweden than in most other included countries. Sodium content in processed food was nonetheless high also in Sweden, and especially so in increasingly consumed food categories, such as "convenience foods".

An mHealth-based school health education system designed to scale up salt reduction in China (EduSaltS): A development and preliminary implementation study

Background

High-salt diet is an important risk factor for several non-communicable diseases. School-based health education has been found effective in reducing salt intake among children and their families in China. However, no such interventions have been scaled up in the real world. For this purpose, a study was launched to support the development and scale-up of an mHealth-based system (EduSaltS) that integrated routine health education and salt reduction and was delivered through primary schools. This study aims to elaborate the framework, development process, features, and preliminary scaling-up of the EduSaltS system.

Methods

The EduSaltS system evolved from previously successfully tested interventions to reduce family salt intake by empowering schoolchildren through school health education. EduSaltS was designed by following the WHO's conceptual framework for developing a scaling-up strategy which accounted for the nature of the innovation, the capacity of the implementing organizations, the characteristics of the environment, the resources available, and type of scaling up. The system was then developed step by step from determination of online platform architecture, definition of component interventions and activities, development of specific educational materials and tools, to the development of the online/offline hybridized system. The system was tested and refined by a pilot in two schools and a preliminary scale-up in two cities in China.

Results

EduSaltS was developed as an innovative health education system, including an online WeChat-based education platform, a set of offline activities, and an actual administrative website showing the progress and setting the system. The WeChat platform could be installed on users' smartphones to automatically deliver 20 sessions of five-minute well-structured cartoon video classes, followed by other online interactive activities. It also helps support project implementation and real-time performance evaluation. As a first-stage roll-out, a one-year course has been successfully implemented among 54,538 children and their families from 209 schools in two cities, and the average course completion rate was 89.1%.

Conclusion

As an innovative mHealth-based health education system, EduSaltS was developed based on successfully tested interventions and an appropriate framework for scaling up. The early-stage roll-out has shown its preliminary scalability, and further evaluation is ongoing.

Reduction of Excessive Dietary Sodium Consumption: Effectiveness of a Prevention Intervention among Health Workers in a Large Italian Hospital

Excessive salt consumption is one of the leading causes of high blood pressure. Worldwide salt intake largely exceeds the WHO recommended amount. This study aimed to evaluate the prevalence of high salt consumers and the effectiveness of a short-term workplace educational intervention among health workers. An online survey, assessing daily salt consumption through the MINISAL-SIIA questionnaire, was sent to the 4911 health workers employed by the University Hospital of Verona, Italy. Health workers who had a high (total score ≥ 10) or moderate (total score = 8/9) salt consumption associated with obesity or arterial hypertension were invited to undergo a medical examination and a short individual counselling session. A total of 1665 health workers (34.0%) completed the online questionnaire; 40.9% and 12.6% had moderate and high salt intake, respectively. High salt intake was more prevalent in men, current and past smokers, and obese and overweight subjects. In 95 participants completing the clinical phase, median daily salt consumption decreased from 10 (p25-p75 8-11) to 7 g (6-8) (p < 0.001), systolic blood pressure from 130 (120-140) to 120 (120-130) mmHg and weight from 78 (62-87) to 75 (62-86) kg. More than half of health workers had an excessive salt intake. However, a brief educational intervention in the healthcare working setting can substantially reduce unhealthy dietary habits, fostering weight loss and blood pressure control. Studies with a longer follow-up are needed to evaluate the persistence over time of these effects.

Addressing global disparities in blood pressure control: perspectives of the International Society of Hypertension

Raised blood pressure (BP) is the leading cause of preventable death in the world. Yet, its global prevalence is increasing, and it remains poorly detected, treated, and controlled in both high- and low-resource settings. From the perspective of members of the International Society of Hypertension based in all regions, we reflect on the past, present, and future of hypertension care, highlighting key challenges and opportunities, which are often region-specific. We report that most countries failed to show sufficient improvements in BP control rates over the past three decades, with greater improvements mainly seen in some high-income countries, also reflected in substantial reductions in the burden of cardiovascular disease and deaths. Globally, there are significant inequities and disparities based on resources, sociodemographic environment, and race with subsequent disproportionate hypertension-related outcomes. Additional unique challenges in specific regions include conflict, wars, migration, unemployment, rapid urbanization, extremely limited funding, pollution, COVID-19-related restrictions and inequalities, obesity, and excessive salt and alcohol intake. Immediate action is needed to address suboptimal hypertension care and related disparities on a global scale. We propose a Global Hypertension Care Taskforce including multiple stakeholders and societies to identify and implement actions in reducing inequities, addressing social, commercial, and environmental determinants, and strengthening health systems implement a well-designed customized quality-of-care improvement framework.

Estimated Dietary and Health Impact of the World Health Organization's Global Sodium Benchmarks on Packaged Foods in Australia: a Modeling Study

BACKGROUND

In 2021, the World Health Organization (WHO) set sodium benchmarks for packaged foods to guide countries in setting feasible and effective sodium reformulation programs. We modeled the dietary and health impact of full compliance with the WHO's sodium benchmarks in Australia and compared it to the potential impact of Australia's 2020 sodium reformulation targets.

METHODS

We used nationally representative data on food and sodium intake, sodium levels in packaged foods, and food sales volume to estimate sodium intake pre- and post-implementation of the WHO and Australia's sodium benchmarks for 24 age-sex groups. Using comparative risk assessment models, we then estimated the potential deaths, incidence, and disability-adjusted life years averted from cardiovascular disease, chronic kidney disease, and stomach cancer based on the reductions in sodium intake.

RESULTS

Compliance with the WHO's sodium benchmarks for packaged foods in Australia could lower mean adult sodium intake by 404 mg/day, corresponding to a 12% reduction. This could prevent about 1770 deaths/year (95% uncertainty interval 1168-2587), corresponding to 3% of all cardiovascular disease, chronic kidney disease, and stomach cancer deaths in Australia, and prevent some 6900 (4603-9513) new cases, and 25 700 (17 655-35 796) disability-adjusted life years/year. Compared with Australian targets, the WHO benchmarks will avert around 3 and a half times more deaths each year (1770 versus 510).

CONCLUSIONS

Substantially greater health impact could be achieved if the Australian government strengthened its current sodium reformulation program by adopting WHO's more stringent and comprehensive sodium benchmarks.

Sodium reduction in foods: Challenges and strategies for technical solutions

In many parts of the world, sodium consumption is higher than recommended levels, representing one of the most important food-related health challenges and leading to considerable economical costs for society. Therefore, there is a need to find technical solutions for sodium reduction that can be implemented by food producers and within food services. The aims of this review are to discuss the barriers related to sodium reduction and to highlight a variety of technical solutions. The barriers relate to consumer perception, microbiology, processing, and physicochemistry. Existing technical solutions include inhomogeneous salt distribution, coated salt particles, changing particle sizes and forms, surface coating, multisensory combinations, sodium replacements, double emulsions, adapted serum release by microstructure design, and adapted brittleness by microstructure design. These solutions, their implementation and the associated challenges, and applicable product categories are described. Some of these solutions are ready for use or are in their early development stages. Many solutions are promising, but in most cases, some form of adaptation or optimization is needed before application in specific products, and care must always be taken to ensure food safety. For instance, further research and innovation are required in the dynamic evolution of saltiness perception, consumer acceptance, the binding and migration of sodium, juiciness, microbiological safety, and the timing of salt addition during processing. Once implemented, these solutions will undoubtedly support food producers and food services in reducing sodium content and extend the application of the solutions to different foods.

Identifying correlates of salt reduction practices among rural, middle-aged Muslim Indonesians with hypertension through structural equation modeling

Background: In 2016, the World Health Organization recommended salt reduction strategies. In most low- and middle-income countries, little is known about what causes people to reduce their salt intake. Aim: In rural West Java, Indonesia, we conducted a cross-sectional survey to describe self-reported salt reduction practices among middle-aged Muslims with hypertension (n = 447) and to identify correlates of salt reduction. Methods: We developed a questionnaire with Likert scales to measure self-reported frequency of efforts to reduce salt intake, and degree of agreement/disagreement with 51 statements about variables hypothesized to influence salt reduction practices. We compared groups using t-tests and one-way ANOVAs. Through one-factor confirmatory factor analysis and structural equation modeling, we identified correlates of salt reduction practices. Results: About 45% of participants reported regularly reducing their salt intake; only 12.8% reported never attempting. Men reported higher social barriers, while women reported higher family support and spiritual support. Overall, we found that participants' frequency of effort to reduce their salt intake was associated with a constellation of six correlates. Salt reduction practices were directly positively associated with prior health/illness experiences (β = 0.25), and by seeking health information (β = 0.24). Seeking health information was in turn positively associated with prior health/illness experiences (β = 0.34), receiving support from health professionals (β = 0.23) and Islamic spiritual practice (β = 0.24). Salt reduction practices were negatively associated with environmental barriers to healthful eating practices (β = -0.14). Conclusion: In this population, reinforcing positive correlates identified in this study and mitigating against negative correlates may foster salt reduction practices.

The perspective of hypertension and salt intake in Chinese population

Salt intake is too high nowadays. It has been widely recognized that there is a close relationship between hypertension (HTN) and dietary salt intake. Investigations reveal that long-term high salt intake, mainly sodium intake, induces a relevant increase in blood pressure in hypertensive and normotensive individuals. According to most scientific evidence, a diet with high salt intake in public increases cardiovascular risk, salted-related HTN, and other HTN-associated outcomes. Given the clinical importance, this review aims to present the prevalence of HTN and trends in salt intake in the Chinese population and will comprehensively discuss the risk factors, causes, and mechanisms of the association between salt intake and HTN. The review also highlights the education of Chinese people regarding salt intake and the cost-effectiveness of salt reduction from a global perspective. Finally, the review will emphasize the need to customize the unique Chinese practices to reduce salt intake and how awareness changes people's eating lifestyle and helps adopt diet salt reduction strategies.

Perceptions, barriers and enablers of salt reduction in Malaysian out-of-home sectors (MySaltOH): from the point of view of policy-makers and food industries

BACKGROUND

High salt intake is a major cause of hypertension and cardiovascular diseases. The out-of-home sectors have been identified as one of the contributors of high salt intake in the population. The National Salt Reduction Policy of Malaysia was initiated in 2015; however, out-of-home sectors are yet to be emphasized and perception by policy-makers and the food industries towards salt reduction are yet unknown. This study aimed to determine the perceptions, barriers and enablers towards salt reduction in the out-of-home sector in Malaysia, as well as among policy-makers and the food industries.

METHODS

This is a qualitative study via semi-structured in-depth interviews (IDI) and focus group discussions (FGD) involving several stakeholders consisting of policy-makers from five ministries, five nongovernment organizations (NGOs) and food science/food technology researchers from five regions (West, North, East, and South Peninsular and East Malaysia/Borneo), as well as the food industries. The IDI and FGD sessions were recorded, transcribed verbatim and analysed thematically using Nvivo software version 12.

RESULTS

All participants agreed that salt intake in Malaysia is high and leads to hypertension and cardiovascular diseases. Lack of awareness, poor eating culture and behaviour and frequent eating out were among the causes of high salt intake. Awareness campaigns and education, sodium content labelling and product reformulation were strategies that have been implemented by the government; whilst for the food industries, some of them have tried to reduce salt and labelled the sodium content on their food products. However, there were several barriers including perceived poor consumer acceptance, lack of knowledge and resources, and challenges in reformulation, as well as unavailability of guidelines and salt targets. Hence, several enablers have been suggested, which include prioritizing the salt reduction strategy, creating more awareness, collaboration and engagement, research and technology particularly for reformulation and shelf-life stability, incentives and salt tax.

CONCLUSIONS

Salt reduction efforts of the out-of-home sector in Malaysia could be achieved through several measures or enablers that can overcome the barriers currently faced by stakeholders, especially policy-makers, food industries and the consumers themselves. This study will benefit the policy-makers to improve the salt reduction policy of out-of-home sectors and highlight the concerns among the food industries on the policy.

Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up

BACKGROUND

To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions.

METHODS

From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions.

RESULTS

Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum.

CONCLUSION

We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

What do we Need to Start a Multimedia Salt Reduction Campaign?

As reports of the first national study reveal, Iranian salt intake reaches 9.52 g/day (two times more than recommended by World Health Organization). Meanwhile ignoring the consequences of high salt intake has led to an increased rate of cardiovascular diseases (CVD), stroke, stomach cancer, osteoporosis, obesity, etc., To tackle these threatening issues, a nationwide intervention campaign could be an effective solution based on global experiences. A review of previous work in Iran shows that despite numerous efforts conducted in the prevention of CVDs, they were not well reflected in worldwide sources. Furthermore, a comprehensive campaign was not implemented particularly concerning the salt reduction in Iran. As a result, we first reviewed the major successful initiatives conducted in reducing salt intake around the world and Iran. Then we introduced the components of a comprehensive social marketing campaign along with customized actions related to Iranian nutrition habits, their attitude, and behavior toward salt consumption. These employed components were SWOT analysis, identifying target group, determining communication goals and objectives based on models and theories, planning executive plan, designing communication messages and materials, media planning and promotional actions, and determining campaign budget plus monitoring and evaluation.

Estimating Canadian sodium intakes and the health impact of meeting national and WHO recommended sodium intake levels: A macrosimulation modelling study

BACKGROUND

Cardiovascular diseases (CVDs) are the second leading cause of total deaths in Canada. High blood pressure is the main metabolic risk factor for developing CVDs. It has been well established that excess consumption of sodium adversely affects blood pressure. Canadians' mean sodium intakes are well above recommended levels. Reducing dietary sodium intake through food reformulation has been identified as a cost-effective intervention, however, dietary sodium intake and the potential health impact of meeting recommended sodium intake levels due to food reformulation have not been determined in Canada.

OBJECTIVE

This study aimed to 1) obtain robust estimates of Canadians' usual sodium intakes, 2) model sodium intakes had foods been reformulated to align with Health Canada's sodium reduction targets, and 3) estimate the number of CVD deaths that could be averted or delayed if Canadian adults were to reduce their mean sodium intake to recommended levels under three scenarios: A) 2,300 mg/d-driven by a reduction of sodium levels in packaged foods to meet Health Canada targets (reformulation); B) 2,000 mg/d to meet the World Health Organization (WHO) recommendation; and C) 1,500 mg/d to meet the Adequate Intake recommendation.

METHODS

Foods in the University of Toronto's Food Label Information Program 2017, a Canadian branded food composition database, were linked to nationally representative food intake data from the 2015 Canadian Community Health Survey-Nutrition to estimate sodium intakes (and intakes had Health Canada's reformulation strategy been fully implemented). The Preventable Risk Integrated ModEl (PRIME) was used to estimate potential health impact.

RESULTS

Overall, mean sodium intake was 2758 mg/day, varying by age and sex group. Based on 'reformulation' scenario A, mean sodium intakes were reduced by 459 mg/day, to 2299 mg/day. Reducing Canadians' sodium intake to recommended levels under scenarios A, B and C could have averted or delayed 2,176 (95% UI 869-3,687), 3,252 (95% UI 1,380-5,321), and 5,296 (95% UI 2,190-8,311) deaths due to CVDs, respectively, mainly from ischaemic heart disease, stroke, and hypertensive disease. This represents 3.7%, 5.6%, and 9.1%, respectively, of the total number of CVDs deaths observed in Canada in 2019.

CONCLUSION

Results suggest that reducing sodium intake to recommended levels could prevent or postpone a substantial number of CVD deaths in Canada. Reduced sodium intakes could be achieved through reformulation of the Canadian food supply. However, it will require higher compliance from the food industry to achieve Health Canada's voluntary benchmark sodium reduction targets.

High sodium diet intake and cardiovascular diseases: An attributable death study in Tianjin, China

There is clear evidence that high sodium intake is associated with many health issues including hypertension and cardiovascular diseases (CVDs). Several national and worldwide studies have estimated deaths from CVDs attributable to high sodium. But how to evaluate the impact of high sodium intake on diseases using regional routine monitoring and investigation data is necessary and important. Our study aimed to quantitatively evaluate the high sodium intake attributed to CVDs deaths based on the routine monitoring data from China National Nutrition and Health Survey (CNNHS) in Tianjin, China. The population attributable fractions (PAF) were calculated by comparing the observed systolic blood pressure (SBP) distribution with the theoretical minimum or counterfactual distribution by sex and age groups. The results showed that CVDs deaths due to elevated SBP were 22728 (95% uncertainty intervals: 22679-23050), accounting for 62.8% of total CVDs deaths. According to sodium intake recommended by World Health Organization (WHO), PAF of CVDs deaths attributable to high sodium diet in our study was 14.6% of total CVDs deaths, accounting for 5228 (95% UI: 5005-5998) cases. The dietary sodium intake of residents is nearly three times than sodium intake recommended by WHO. If sodium intake was reduced to reference level, the potential avoidable CVD deaths attributable to the SBP-raising effect were more than 5200 among adults 25 aged and over in Tianjin. This evaluation method can be extended to other cities.

Effect of Salt Addition and Fermentation Time on Phenolics, Microbial Dynamics, Volatile Organic Compounds, and Sensory Properties of the PDO Table Olives of Gaeta (Italy)

'Oliva di Gaeta' is almost certainly the most important and well-known PDO denomination for table olives in Italy. Their production is based on a specific two-stage trade preparation called the 'Itrana' method. In this work, we investigated how variations in the duration of the initial water fermentation (i.e., 15 and 30 days) and the salt concentration (i.e., 6% and 8% NaCl) influence the chemical features, microbial dynamics, polyphenols, volatile organic compounds, and sensory features of 'Oliva di Gaeta'. The time of the addition of salt did not affect the final concentration in the brine, but a longer initial water fermentation (before salt addition) led to lower pH values. The bacterial count constantly increased until the salt addition (i.e., either 15 or 30 days), while the yeast population peaked on day 30. Generally, the two different salt concentrations did not affect the count of microorganisms at the end of fermentation, with the only exception being a higher lactic acid bacteria count for the treatment with 6% salt added at 30 days. At commercial maturity, the crucial bitter tastant oleuropein was not completely removed from the drupes, and differences in salt concentration and the length of the first-stage water fermentation did not influence its content at the end of olive curing. Richer volatile profiles of olives were detected with higher-salt treatments, while the combination of low salt and early saline treatment provided a more distinct profile. Longer initial water fermentation caused a small increase in some phenolic compounds (e.g., iso-verbascoside, verbascoside, and hydroxytyrosol-glucoside). A panel test indicated that salt application at 30 days resulted in a more "Sour" and "Bitter" taste, irrespective of the salt concentration. The low salt concentration coupled with the late saline treatment resulted in more "Fruity" notes, probably due to the higher production of esters by lactobacilli. The slightly bitter perception of the olives was consistent with the partial removal of oleuropein. Our work revealed the characteristics of the 'Itrana' method and that the variation in salt concentration and its time of application changes parameters ranging from the microbial dynamics to the sensory profile. Specifically, our data indicate that 6% NaCl coupled with a longer initial water fermentation is the most different condition: it is less effective in blocking microbial growth but, at the same time, is more potent in altering the nutritional (e.g., polyphenols) and sensorial qualities (e.g., bitterness and fruitiness) of 'Oliva di Gaeta'.

24-hour sodium and potassium excretion in the Americas: a systematic review and meta-analysis

Objective

To determine the 24-hour urinary sodium and potassium excretions in the Americas.

Methods

A systematic review and meta-analysis were performed seeking for studies conducted between 1990 and 2021 in adults living in any sovereign state of the Americas in Medline, Embase, Scopus, SciELO, and Lilacs. The search was first run on October 26th, 2020 and was updated on December 15th, 2021. Of 3 941 abstracts reviewed, 74 studies were included from 14 countries, 72 studies reporting urinary sodium (27 387 adults), and 42 studies reporting urinary potassium (19 610 adults) carried out between 1990 and 2020. Data were pooled using a random-effects meta-analysis model.

Results

Mean excretion was 157.29 mmol/24h (95% CI, 151.42-163.16) for sodium and 57.69 mmol/24h (95% CI, 53.35-62.03) for potassium. When only women were considered, mean excretion was 135.81 mmol/24h (95% CI, 130.37-141.25) for sodium and 51.73 mmol/24h (95% CI, 48.77-54.70) for potassium. In men, mean excretion was 169.39 mmol/24h (95% CI, 162.14-176.64) for sodium and 62.67 mmol/24h (95% CI, 55.41-69.93) for potassium. Mean sodium excretion was 150.09 mmol/24h (95% CI, 137.87-162.30) in the 1990s and 159.79 mmol/24h (95% CI, 151.63-167.95) in the 2010s. Mean potassium excretion was 58.64 mmol/24h (95% CI, 52.73-64.55) in the 1990s and 56.33 mmol/24/h (95% CI, 48.65-64.00) in the 2010s.

Conclusions

These findings suggest that sodium excretions are almost double the maximum level recommended by the World Health Organization and potassium excretions are 35% lower than the minimum requirement; therefore, major efforts to reduce sodium and to increase potassium intakes should be implemented.

Building capacity in reducing population dietary sodium intake in the Americas

Objective.

To present some resources developed as part of the technical support of the Pan American Health Organization (PAHO) to Member States to reduce population dietary sodium intake, and to discuss the main challenges and opportunities to accelerate action toward sodium intake reduction in the Americas.

Methods.

Sources of information include a mapping of salt reduction policies conducted in 2019, reports from working group meetings, interviews conducted in 2020 and 2021 in seven countries, and technical documents developed around the Updated PAHO Regional Sodium Reduction Targets.

Results.

These tools show that, despite progress, challenges to succeed in this agenda persist. Priority given to sodium reduction is low in most countries, with insufficient resource allocation. There is a lack of intersectoral coordinated action, and a systemic approach to food systems is commonly missing. Surveillance mechanisms of sodium intake are insufficient, and industry interference in policy processes is commonly identified, undermining policy progress and success. There are also important regional opportunities to address these challenges. These include common ground for future collaborations by updating, strengthening, and complementing these existing tools, and technical and financial support for data generation.

Conclusions.

PAHO is committed to continue to support countries in the process of promoting, implementing, and monitoring cost-effective sodium reduction interventions. One key policy priority in this agenda is the adoption of the Updated PAHO Regional Sodium Reduction Targets with a mandatory approach, together with the comprehensive and complementary implementation of other strategies. Strong political will and commitment of countries will be critical to translate goals into concrete achievements in the Americas.