Kathy Trieu

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.

Review of behaviour change interventions to reduce population salt intake.

BackgroundExcess salt intake is a major cause of raised blood pressure—the leading risk factor for death and disability worldwide. Although behaviour change interventions such as awareness campaigns and health education programs are implemented to reduce salt intake, their effectiveness is unclear. This global systematic review investigates the impact of population-level behaviour change interventions that aim to reduce salt intake.MethodsA search for published and grey literature was conducted using PubMed, Cochrane Library, Embase, Web of Science, Sage, Scopus, OpenGrey, Google Scholar and other relevant organizations’ websites. Studies were included if 1) published between 2005 and 2015; 2) the education or awareness-raising interventions were aimed at the population or sub-population and 3) salt intake and/or salt-related behaviours were outcome measures. Study and intervention characteristics were extracted for the descriptive synthesis and study quality was assessed.ResultsTwenty two studies involving 41,448 participants were included. Most were conducted in high income countries (n = 16), targeting adults (n = 21) in the general population (n = 16). Behaviour change interventions were categorised as health education interventions (n = 14), public awareness campaigns (n = 4) and multi-component interventions (including both health education and awareness campaigns, n = 4). 19 of the 22 studies demonstrated significant reductions in estimated salt intake and/or improvement in salt-related behaviours. All studies showed high risk of bias in one or more domains. Of the 10 higher quality studies, 5 found a significant effect on salt intake or salt behaviours based on the more objective outcome assessment method.ConclusionBased on moderate quality of evidence, population-level behaviour change interventions can improve salt-related behaviours and/or reduce salt intake. However, closer analysis of higher quality studies show inconsistent evidence of the effectiveness and limited effect sizes suggest the implementation of education and awareness-raising interventions alone are unlikely to be adequate in reducing population salt intake to the recommended levels. A framework which guides rigorous research and evaluation of population-level interventions in real-world settings would help understand and support more effective implementation of interventions to reduce salt intake.

Announcing "Up to Date in the Science of Sodium"

From the Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; George Institute for Global Health, University of Sydney, Sydney, NSW, Australia; George Institute for Global Health India, Hyderabad, India; The George Institute for Global Health, University of Sydney and the Royal Prince Alfred Hospital, Sydney, NSW, Australia; Departments of Preventive & Social Medicine/Human Nutrition, University of Otago, Dunedin, New Zealand; Arbor Research Collaborative for Health, Ann Arbor, MI; Department of Medicine, University of Calgary, Calgary, AB, Canada; and Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O’Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary,Calgary, AB, Canada

Salt reduction in Australia: from advocacy to action

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

Effectiveness of a Communication for Behavioral Impact (COMBI) Intervention to Reduce Salt Intake in a Vietnamese Province Based on Estimations From Spot Urine Samples.

This study evaluated the effectiveness of the Communication for Behavioral Impact (COMBI)–Eat Less Salt intervention conducted in Viet Tri, Vietnam. The behavior change intervention was implemented in four wards and four communes for one year, which included mass media communication, school interventions, community programs, and focus on high‐risk groups. Mean sodium excretion was estimated from spot urine samples using different equations. A subsample provided 24‐hour urine to validate estimates from spot urine. Information about salt‐related knowledge and behaviors was also collected. There were 513 participants at both baseline and follow‐up. Mean sodium excretion estimated from spot urines fell significantly from 8.48 g/d at baseline to 8.05 g/d at follow‐up (P=.001). All spot equations demonstrated a significant reduction in sodium levels; however, the change was smaller than the measured 24‐hour urine. Participants showed improved knowledge and behaviors following the intervention. The COMBI intervention was effective in lowering average population salt intake and improving knowledge and behaviors.

Salt Intakes, Knowledge, and Behavior in Samoa: Monitoring Salt‐Consumption Patterns Through the World Health Organization's Surveillance of Noncommunicable Disease Risk Factors (STEPS)

This project measured population salt intake in Samoa by integrating urinary sodium analysis into the World Health Organizations (WHOs) STEPwise approach to surveillance of noncommunicable disease risk factors (STEPS). A subsample of the Samoan Ministry of Healths 2013 STEPS Survey collected 24‐hour and spot urine samples and completed questions on salt‐related behaviors. Complete urine samples were available for 293 participants. Overall, weighted mean population 24‐hour urine excretion of salt was 7.09 g (standard error 0.19) to 7.63 g (standard error 0.27) for men and 6.39 g (standard error 0.14) for women (P=.0014). Salt intake increased with body mass index (P=.0004), and people who added salt at the table had 1.5 g higher salt intakes than those who did not add salt (P=.0422). A total of 70% of the population had urinary excretion values above the 5 g/d cutoff recommended by the WHO. A reduction of 30% (2 g) would reduce average population salt intake to 5 g/d, in line with WHO recommendations. While challenging, integration of salt monitoring into STEPS provides clear logistical and cost benefits and the lessons communicated here can help inform future programs.

The Science of Salt: A Systematic Review of Quality Clinical Salt Outcome Studies June 2014 to May 2015

Studies identified from an updated systematic review (from June 2014 to May 2015) on the impact of dietary salt intake on clinical and population health are reviewed. Randomized controlled trials, cohort studies, and meta‐analyses of these study types on the effect of sodium intake on blood pressure, or any substantive adverse health outcomes were identified from MEDLINE searches and quality indicators were used to select studies that were relevant to clinical and public health. From 6920 studies identified in the literature search, 144 studies were selected for review, of which only three (n=233,680) met inclusion criteria. Between them, the three studies demonstrated a harmful association between excess dietary salt and all‐cause mortality, noncardiovascular and cardiovascular disease mortality, and headache. None of the included studies found harm from lowering dietary salt. The findings of this systematic review are consistent with the large body of research supportive of efforts to reduce population salt intake and congruent with our last annual review from June 2013 to May 2014.

A systematic review of economic evaluations of population-based sodium reduction interventions

Objective To summarise evidence describing the cost-effectiveness of population-based interventions targeting sodium reduction. Methods A systematic search of published and grey literature databases and websites was conducted using specified key words. Characteristics of identified economic evaluations were recorded, and included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results Twenty studies met the study inclusion criteria and received a full paper review. Fourteen studies were identified as full economic evaluations in that they included both costs and benefits associated with an intervention measured against a comparator. Most studies were modelling exercises based on scenarios for achieving salt reduction and assumed effects on health outcomes. All 14 studies concluded that their specified intervention(s) targeting reductions in population sodium consumption were cost-effective, and in the majority of cases, were cost saving. Just over half the studies (8/14) were assessed as being of ‘excellent’ reporting quality, five studies fell into the ‘very good’ quality category and one into the ‘good’ category. All of the identified evaluations were based on modelling, whereby inputs for all the key parameters including the effect size were either drawn from published datasets, existing literature or based on expert advice. Conclusion Despite a clear increase in evaluations of salt reduction programs in recent years, this review identified relatively few economic evaluations of population salt reduction interventions. None of the studies were based on actual implementation of intervention(s) and the associated collection of new empirical data. The studies universally showed that population-based salt reduction strategies are likely to be cost effective or cost saving. However, given the reliance on modelling, there is a need for the effectiveness of new interventions to be evaluated in the field using strong study designs and parallel economic evaluations.

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

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.