Elizabeth Dunford

Salt reduction initiatives around the world

Objective To provide an overview of national salt reduction initiatives around the world, describe core characteristics and develop a framework for future strategy development. Methods National strategies were identified from existing reviews and from searches of the literature and relevant websites. Standardized information was extracted about governance and strategy development, baseline assessments and monitoring and implementation. Results Thirty-two country salt reduction initiatives were identified. The majority of activity was in Europe (19 countries). Most countries (27) had maximum population salt intake targets, ranging from 5 to 8 g/person per day. Twenty-six of the 32 strategies were led by government, five by nongovernment organizations and one by industry. Twenty-eight countries had some baseline data on salt consumption and 18 had data on sodium levels in foods. Twenty-eight countries were working with the food industry to reduce salt in foods, 10 had front-of-pack labelling schemes and 28 had consumer awareness or behaviour change programs. Five countries had demonstrated an impact, either on population salt consumption, salt levels in foods or consumer awareness. These strategies were led by government and were multifaceted including food reformulation, consumer awareness initiatives and labelling actions. Conclusion This is the first review to concisely summarize the most important elements of the many existing salt reduction programmes and highlight the characteristics most likely to be important to programme efficacy. For most countries, implementing a national salt reduction programme is likely to be one of simplest and most cost-effective ways of improving public health.

A systematic survey of the sodium contents of processed foods

BACKGROUND Processed foods are major contributors to population dietary salt intake. Parts of the Australian food industry have started to decrease salt in a number of products. A definitive baseline assessment of current sodium concentrations in foods is key to targeting reformulation strategies and monitoring progress. OBJECTIVES Our objectives were to systematically collate data on the sodium content of Australian processed food products and compare sodium values against maximum target levels established by the UK Food Standards Agency (UK FSA). DESIGN Categories of processed foods that contribute the majority of salt to Australian diets were identified. Food-composition data were sought for all products in these categories, and the sodium content in mg/100 g (or mg/100 mL for liquids) was recorded for each. Mean sodium values were calculated for each grouping and compared with the UK FSA benchmarks. RESULTS Sodium data were collected for 7221 products in 10 food groups, 33 food categories, and 90 food subcategories. The food groups that were highest in sodium were sauces and spreads (1283 mg/100 g) and processed meats (846 mg/100 g). Cereal and cereal products (206 mg/100 g) and fruit and vegetables (211 mg/100 g) were the lowest in sodium. Sixty-three percent of food categories had mean sodium concentrations above the UK FSA targets, and most had wide ranges between the most and least salty product. CONCLUSIONS Many products, particularly breads, processed meats, and sauces, have salt amounts above reasonable benchmarks. The variation in salt concentrations between comparable products suggests that reformulation is highly feasible for many foods.

Sodium content of processed foods in the United Kingdom: analysis of 44,000 foods purchased by 21,000 households

Background: In the United Kingdom, sodium reduction targets have been set for a large number of processed food categories. Assessment and monitoring are essential to evaluate progress. Objectives: Our aim was to determine whether household consumer panel food-purchasing data could be used to assess the sodium content of processed foods. Our further objectives were to estimate the mean sodium content of UK foods by category and undertake analyses weighted by food-purchasing volumes. Design: Data were obtained for 21,108 British households between October 2008 and September 2009. Purchasing data (product description, product weight, annual purchases) and sodium values (mg/100 g) were collated for all food categories known to be major contributors to sodium intake. Unweighted and weighted mean sodium values were calculated. Results: Data were available for 44,372 food products. The largest contributors to sodium purchases were table salt (23%), processed meat (18%), bread and bakery products (13%), dairy products (12%), and sauces and spreads (11%). More than one-third of sodium purchased (37%) was accounted for by 5 food categories: bacon, bread, milk, cheese, and sauces. For some food groups (bread and bakery, cereals and cereal products, processed meat), purchase-weighted means were 18–35% higher than unweighted means, suggesting that market leaders have higher sodium contents than the category mean. Conclusion: The targeting of sodium reduction in a small number of food categories and focusing on products sold in the highest volumes could lead to large decreases in sodium available for consumption and therefore to gains in public health.

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

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

Target Salt 2025: A Global Overview of National Programs to Encourage the Food Industry to Reduce Salt in Foods

Reducing population salt intake has been identified as a priority intervention to reduce non-communicable diseases. Member States of the World Health Organization have agreed to a global target of a 30% reduction in salt intake by 2025. In countries where most salt consumed is from processed foods, programs to engage the food industry to reduce salt in products are being developed. This paper provides a comprehensive overview of national initiatives to encourage the food industry to reduce salt. A systematic review of the literature was supplemented by key informant questionnaires to inform categorization of the initiatives. Fifty nine food industry salt reduction programs were identified. Thirty eight countries had targets for salt levels in foods and nine countries had introduced legislation for some products. South Africa and Argentina have both introduced legislation limiting salt levels across a broad range of foods. Seventeen countries reported reductions in salt levels in foods—the majority in bread. While these trends represent progress, many countries have yet to initiate work in this area, others are at early stages of implementation and further monitoring is required to assess progress towards achieving the global target.

International collaborative project to compare and monitor the nutritional composition of processed foods

Background: Chronic diseases are the leading cause of premature death and disability in the world with overnutrition a primary cause of diet-related ill health. Excess energy intake, saturated fat, sugar, and salt derived from processed foods are a major cause of disease burden. Our objective is to compare the nutritional composition of processed foods between countries, between food companies, and over time. Design: Surveys of processed foods will be done in each participating country using a standardized methodology. Information on the nutrient composition for each product will be sought either through direct chemical analysis, from the product label, or from the manufacturer. Foods will be categorized into 14 groups and 45 categories for the primary analyses which will compare mean levels of nutrients at baseline and over time. Initial commitments to collaboration have been obtained from 21 countries. Conclusions: This collaborative approach to the collation and sharing of data will enable objective and transparent tracking of processed food composition around the world. The information collected will support government and food industry efforts to improve the nutrient composition of processed foods around the world.

FoodSwitch: a mobile phone app to enable consumers to make healthier food choices and crowdsourcing of National Food Composition Data

Background Front-of-pack nutrition labeling (FoPL) schemes can help consumers understand the nutritional content of foods and may aid healthier food choices. However, most packaged foods in Australia carry no easily interpretable FoPL, and no standard FoPL system has yet been mandated. About two thirds of Australians now own a smartphone. Objective We sought to develop a mobile phone app that would provide consumers with easy-to-understand nutrition information and support the selection of healthier choices when shopping for food. Methods An existing branded food database including 17,000 Australian packaged foods underpinned the project. An iterative process of development, review, and testing was undertaken to define a user interface that could deliver nutritional information. A parallel process identified the best approach to rank foods based on nutritional content, so that healthier alternative products could be recommended. Results Barcode scanning technology was identified as the optimal mechanism for interaction of the mobile phone with the food database. Traffic light labels were chosen as the preferred format for presenting nutritional information, and the Food Standards Australia New Zealand nutrient profiling method as the best strategy for identifying healthier products. The resulting FoodSwitch mobile phone app was launched in Australia in January 2012 and was downloaded by about 400,000 users in the first 18 months. FoodSwitch has maintained a 4-plus star rating, and more than 2000 users have provided feedback about the functionality. Nutritional information for more than 30,000 additional products has been obtained from users through a crowdsourcing function integrated within the app. Conclusions FoodSwitch has empowered Australian consumers seeking to make better food choices. In parallel, the huge volume of crowdsourced data has provided a novel means for low-cost, real-time tracking of the nutritional composition of Australian foods. There appears to be significant opportunity for this approach in many other countries.

The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction

Background: Several fast food companies have made commitments to reduce the levels of salt in the foods they serve, but technical issues are often cited as a barrier to achieving substantial reductions. Our objective was to examine the reported salt levels for products offered by leading multinational fast food chains. Methods: Data on salt content for products served by six fast food chains operating in Australia, Canada, France, New Zealand, the United Kingdom and the United States were collected by survey in April 2010. Mean salt contents (and their ranges) were calculated and compared within and between countries and companies. Results: We saw substantial variation in the mean salt content for different categories of products. For example, the salads we included in our survey contained 0.5 g of salt per 100 g, whereas the chicken products we included contained 1.6 g. We also saw variability between countries: chicken products from the UK contained 1.1 g of salt per 100 g, whereas chicken products from the US contained 1.8 g. Furthermore, the mean salt content of food categories varied between companies and between the same products in different countries (e.g., McDonald’s Chicken McNuggets contain 0.6 g of salt per 100 g in the UK, but 1.6 g of salt per 100 g in the US). Interpretation: The salt content of fast foods varies substantially, not only by type of food, but by company and country in which the food is produced. Although the reasons for this variation are not clear, the marked differences in salt content of very similar products suggest that technical reasons are not a primary explanation. In the right regulatory environment, it is likely that fast food companies could substantially reduce the salt in their products, translating to large gains for population health.

Nutrient content of products served by leading Australian fast food chains.

With more consumers purchasing meals outside the home, fast food products contribute substantially to daily energy intakes. Improving the nutrient composition of fast food would have significant health benefits. Nutrient content data for menu items provided by nine companies representing >90% of the fast food market in Australia were collected. Mean nutrient levels were compared between product categories and compared to currently accepted criteria for healthy foods. The majority of fast food products did not meet criteria for healthy options. Breakfast items had the highest mean sugar content (7.8 g/100 g) and saturated fat (5.5 g/100 g), and chicken items the highest total fat (13.2 g/100 g) and sodium (586 mg/100 g). There was marked variation in nutrient levels between similar products. There was a 10-fold variation in the total fat, saturated fat and sugar content of sandwiches, an 8-fold variation in saturated fat in burgers and >20-fold variation in the sugar and total fat content of salads. Differences were even greater per serve. The considerable variation in the nutrient content of comparable products suggests significant potential for reformulation. Even small improvements in composition could produce important health gains if implemented across all product categories by all companies in unison.

Changes in the sodium content of bread in Australia and New Zealand between 2007 and 2010: implications for policy

Objective: To define the effectiveness of recent efforts by the Australian Division of World Action on Salt and Health, and the Heart Foundation in New Zealand to reduce sodium levels in breads in Australia and New Zealand.