Anthea Christoforou

Salt intake assessed by 24 h urinary sodium excretion in a random and opportunistic sample in Australia

Objective The gold standard method for measuring population sodium intake is based on a 24 h urine collection carried out in a random population sample. However, because participant burden is high, response rates are typically low with less than one in four agreeing to provide specimens. At this low level of response it is possible that simply asking for volunteers would produce the same results. Setting Lithgow, New South Wales, Australia. Participants We randomly selected 2152 adults and obtained usable 24 h urine samples from 306 (response rate 16%). Specimens were also collected from a further 113 volunteers. Estimated salt consumption and the costs for each strategy were compared. Results The characteristics of the ‘random’ and ‘volunteer’ samples were moderately different in mean age 58 (SD 14.6 vs 49(17.7) years, respectively; p<0.001) as well as self-reported alcohol use, tobacco use, history of hypertension and prescription drug use (all p<0.04). Overall crude mean 24 h urinary salt excretion was 8.9(3.6) g/day in the random sample vs 8.5(3.3) g/day for the volunteers (p=0.42). Corresponding age-adjusted and sex-adjusted estimates were 9.2(3.3) and 8.8(3.4) g/day (p=0.29). Estimates for men 10.3(3.8) vs 9.6(3.3) g/day; (p=0.26) and women 7.6(3) vs 7.9(3.2) g/day; (p=0.43) were also similar for the two samples, as was salt excretion across age groups (p=0.72). The cost of obtaining each 24 h urine sample was two times greater for the random compared to volunteer samples (

Changes in the sodium content of Australian ready meals between 2008 and 2011.

A62 vs

Cost-effectiveness of reducing salt intake in the Pacific Islands: protocol for a before and after intervention study

A31). Conclusions The estimated salt consumption derived from the two samples was comparable and was not substantively different to estimates obtained from other surveys. In countries where salt is pervasive and cannot easily be avoided, estimates of consumption obtained from volunteer samples may be valid and less costly.

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

Australians consume substantially more sodium than recommended. Three quarters of dietary sodium derives from processed food and the growing ready meal category is a significant contributor. This study examined changes in sodium levels of Australian ready meal products between 2008 and 2011. Sodium data were systematically collected from all product labels in the same 5 stores each year. Mean sodium levels were calculated overall and compared between ready meal types, and by major brands. The levels of sodium in new, discontinued and established products were also compared. There were 107 ready meal products in 2008, 313 in 2009, 219 in 2010 and 265 in 2011. Overall mean sodium content was unchanged between 2008 and 2011 (279 vs 277 mg/100g). There were clear differences between sodium levels of different brands (222 vs 310 mg/100g in McCain Healthy Choice and McCain products respectively) and marked variation in similar products (240 mg/100g in one brand of frozen cottage pie product vs 425mg/100g in another). The mean sodium content of recently introduced products was lower than discontinued products (289 vs 309 mg/100g), with the sodium level of established products remaining stable. The absence of any overall reduction in sodium levels of Australian ready meal products is discouraging. The failure of voluntary industry efforts to reduce the saltiness of these foods suggests a regulated approach will be required to drive product reformulation.

State-level and community-level salt reduction initiatives: a systematic review of global programmes and their impact

BackgroundThere is broad consensus that diets high in salt are bad for health and that reducing salt intake is a cost-effective strategy for preventing chronic diseases. The World Health Organization has been supporting the development of salt reduction strategies in the Pacific Islands where salt intakes are thought to be high. However, there are no accurate measures of salt intake in these countries. The aims of this project are to establish baseline levels of salt intake in two Pacific Island countries, implement multi-pronged, cross-sectoral salt reduction programs in both, and determine the effects and cost-effectiveness of the intervention strategies.Methods/DesignIntervention effectiveness will be assessed from cross-sectional surveys before and after population-based salt reduction interventions in Fiji and Samoa. Baseline surveys began in July 2012 and follow-up surveys will be completed by July 2015 after a 2-year intervention period.A three-stage stratified cluster random sampling strategy will be used for the population surveys, building on existing government surveys in each country. Data on salt intake, salt levels in foods and sources of dietary salt measured at baseline will be combined with an in-depth qualitative analysis of stakeholder views to develop and implement targeted interventions to reduce salt intake.DiscussionSalt reduction is a global priority and all Member States of the World Health Organization have agreed on a target to reduce salt intake by 30% by 2025, as part of the global action plan to reduce the burden of non-communicable diseases. The study described by this protocol will be the first to provide a robust assessment of salt intake and the impact of salt reduction interventions in the Pacific Islands. As such, it will inform the development of strategies for other Pacific Island countries and comparable low and middle-income settings around the world.

Food Fortification in Canada

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

The association of knowledge, attitudes and behaviours related to salt with 24-hour urinary sodium excretion

Background High-salt diets are linked to elevated blood pressure, a major risk factor for cardiovascular diseases, particularly stroke. State and community salt reduction strategies may complement nationally led initiatives and contribute to achieving global salt reduction targets. We aim to systematically review such interventions and document reported impact where programmes have been evaluated. Methods Electronic databases were searched up to June 2015 using terms ‘salt’ or ‘sodium’ and ‘state’ and ‘community’ in combination with ‘campaign’, ‘initiative’, ‘project’, ‘strategy’, ‘intervention’ or ‘programme’. Data from evaluated and unevaluated interventions were included. Studies were analysed in relation to intervention components and outcome measures and appraised for quality using a Cochrane Risk-of-Bias Tool. Results 39 state and community programmes were identified. Settings varied from whole communities (n=23), state-owned buildings (n=5), schools (n=7), workplaces (n=3) and correctional facilities (n=1). Strategies included nutrition education programmes, public education campaigns, changes to the food environment, other ‘novel’ approaches and multifaceted approaches. Of the 28 studies that evaluated intervention effectiveness, significant reductions were observed in terms of salt intake from dietary assessment (n=7), urinary sodium excretion (n=8), blood pressure (n=11) and sodium in foods (n=9). Six studies reported positive changes in consumer knowledge, attitudes and behaviours. All but two studies had some methodological limitations. Conclusions State and community salt reduction programmes may be effective in a range of settings but more robust evaluation methods are needed. Scaling up these efforts in coordination with national initiatives could provide the most effective and sustainable approach to reducing population salt intake.

Setting targets for salt levels in foods: A five-step approach for low- and middle-income countries

Abstract Historically, food fortification practices in Canada have been tightly regulated to respond to nutrient deficiencies observed in the population. More recently however, Canada has observed the liberalization of fortification through the manufacturer-driven practice of discretionary fortification. Evidence has begun to suggest that this practice is both incongruent with the nutritional needs of the population and may in fact inadvertently lead to nutrient exposures deleterious to health, particularly for certain vulnerable groups, such as children. Discretionary fortified products have furthermore been observed to be high in certain nutrients to limit and to be more heavily marketed raising concerns about the displacement of healthier options from the diet. The Canadian experience represents a unique example of a country that has matured in addressing initial fortification needs and is now confronted with new challenges in managing nutrient additions to foods outside of mandatory programs. As discretionary fortification continues to expand and evolve, more work is needed to characterize this practice of manufacturers, and consumers’ response to it, so to better inform policy aimed at optimizing the nutritional status of Canadians.