Salt need needs investigation.

Expensive and extensive studies on the epidemiology of excessive Na intake and its pathology have been conducted over four decades. The resultant consensus that dietary Na is toxic, as well as the contention that it is less so, ignores the root cause of the attractiveness of salted food. The extant hypotheses are that most Na is infiltrated into our bodies via heavily salted industrialised food without our knowledge and that mere exposure early in life determines lifelong intake. However, these hypotheses are poorly evidenced and are meagre explanations for the comparable salt intake of people worldwide despite their markedly different diets. The love of salt begins at birth for some, vacillates in infancy, climaxes during adolescent growth, settles into separate patterns for men and women in adulthood and, with age, fades for some and persists for others. Salt adds flavour to food. It sustains and protects humans in exertion, may modulate their mood and contributes to their ailments. It may have as yet unknown benefits that may promote its delectability, and it generates controversy. An understanding of the predilection for salt should allow a more evidence-based and effective reduction of the health risks associated with Na surfeit and deficiency. The purpose of this brief review is to show the need for research into the determinants of salt intake by summarising the little we know.

Estimating the cost-effectiveness of salt reformulation and increasing access to leisure centres in England, with PRIMEtime CE model validation using the AdViSHE tool.

BACKGROUND: PRIMEtime CE is a multistate life table model that can directly compare the cost effectiveness of public health interventions affecting diet and physical activity levels, helping to inform decisions about how to spend finite resources. This paper estimates the costs and health outcomes in England of two scenarios: reformulating salt and expanding subsidised access to leisure centres. The results are used to help validate PRIMEtime CE, following the steps outlined in the Assessment of the Validation Status of Health-Economic decision models (AdViSHE) tool. METHODS: The PRIMEtime CE model estimates the difference in quality adjusted life years (QALYs) and difference in NHS and social care costs of modelled interventions compared with doing nothing. The salt reformulation scenario models how salt consumption would change if food producers met the 2017 UK Food Standards Agency salt reformulation targets. The leisure centre scenario models change in physical activity levels if the Birmingham Be Active scheme (where swimming pools and gym access is free to residents during defined periods) was rolled out across England. The AdViSHE tool was developed by health economic modellers and divides model validation into five parts: validation of the conceptual model, input data validation, validation of computerised model, operational validation, and other validation techniques. PRIMEtime CE is discussed in relation to each part. RESULTS: Salt reformulation was dominant compared with doing nothing, and had a 10-year return on investment of £1.44 (£0.50 to £2.94) for every £1 spent. By contrast, over 10 years the Be Active expansion would cost £727,000 (£514,000 to £1,064,000) per QALY. PRIMEtime CE has good face validity of its conceptual model and has robust input data. Cross-validation produces mixed results and shows the impact of model scope, input parameters, and model structure on cost-per-QALY estimates. CONCLUSIONS: This paper illustrates how PRIMEtime CE can be used to compare the cost-effectiveness of two different public health measures affecting diet and physical activity levels. The AdViSHE tool helps to validate PRIMEtime CE, identifies some of the key drivers of model estimates, and highlights the challenges of externally validating public health economic models against independent data.

Monitoring Sodium Content in Processed Foods in Argentina 2017-2018: Compliance with National Legislation and Regional Targets.

Sodium intake in Argentina has been estimated to be at least double the dose of 2000 mg/day recommended by WHO, mostly coming from processed foods. Argentina is one of the few countries in the world that have regulated sodium content in certain food products. This study presents an assessment of sodium content in a selection of food groups and categories as reported in the nutrient information panels. We surveyed 3674 food products, and the sodium content of 864 and 1375 of them was compared to the maximum levels according to the Argentinean law and the regional targets, respectively. All food categories presented high variability of sodium content. Over 90% of the products included in the national sodium reduction law were found to be compliant. Food groups with high median sodium, such as condiments, sauces and spreads, and fish and fish products, are not included in the national law. In turn, comparisons with the lower regional targets indicated that almost 50% of the products analyzed had sodium contents above the recommended values. This evidence suggests that enhancing sodium reduction in processed foods may be a necessity for public health objectives and it is also technically feasible in Argentina.

Sodium Levels of Processed Meat in Australia: Supermarket Survey Data from 2010 to 2017.

High sodium intake increases blood pressure and consequently increases the risk of cardiovascular diseases. In Australia, the best estimate of sodium intake is 3840 mg sodium/day, almost double the World Health Organization (WHO) guideline (2000 mg/day), and processed meats contribute approximately 10% of daily sodium intake to the diet. This study assessed the median sodium levels of 2510 processed meat products, including bacon and sausages, available in major Australian supermarkets in 2010, 2013, 2015 and 2017, and assessed changes over time. The median sodium content of processed meats in 2017 was 775 mg/100 g (interquartile range (IQR) 483⁻1080). There was an 11% reduction in the median sodium level of processed meats for which targets were set under the government's Food and Health Dialogue (p < 0.001). This includes bacon, ham/cured meat products, sliced luncheon meat and meat with pastry categories. There was no change in processed meats without a target (median difference 6%, p = 0.450). The new targets proposed by the current government's Healthy Food Partnership capture a larger proportion of products than the Food and Health Dialogue (66% compared to 35%) and a lower proportion of products are at or below the target (35% compared to 54%). These results demonstrate that voluntary government targets can drive nutrient reformulation. Future efforts will require strong government leadership and robust monitoring and evaluation systems.

Psychometric Testing of the Indonesian Version of Dietary Sodium Restriction Questionnaire Among Patients with Hypertension.

PURPOSE: The purpose of this research was to test the validity and reliability of the Indonesian version of the Dietary Sodium Restriction Questionnaire (DSRQ-I) among patients with hypertension. METHODS: The cross-sectional study enrolled hypertensive patients from a cardiac outpatient department in Indonesia using convenience sampling. Eligible patients received a demographic questionnaire and DSRQ-I during a one-month period of data collection. Content and construct analysis examined the validity, whereas internal consistency assessment checked reliability. Participation required 10-15 minutes on average. RESULTS: One hundred thirty-five patients participated: mostly females (54.1%) and married (82.9%) with mean age of 58.18 ± 10.44 years. The item of content validity index was .97, and subscale content validity index was .81 for DSRQ-I. The Kaiser-Meyer-Olkin test gave a value of .83, indicating adequate sampling, and the Bartlett's test of sphericity reached significant result (p < .001). The principal component analysis indicated three components, with 64.2% explaining variance, including perceived behavioral control (35.5%), attitude (19.3%), and subjective norm (9.4%). Confirmatory factor analysis produced a parsimonious model on the three-factor outcome by removing a single item. The indices of good fit model was achieved at χ2/df = 2.17, goodness fit index = .85, root mean square error of approximation = .09, standardized root mean square means = .07, and Bentler comparative fit index = .90 (p < .001). Cronbach's alpha coefficients for attitude, subjective norm, and perceived behavioral control were .85, .87, and .85, respectively. All interitem and item-total correlations indicated adequate outcome and acceptable result. Consequently, 15 items were determined reliable measurement and included in the final version of DSRQ-I. CONCLUSION: The DSRQ-I is a valid and reliable instrument to measure facilitators and barrier of sodium restriction among hypertensive patients in Indonesia.

The Sodium Content of Processed Foods in South Africa during the Introduction of Mandatory Sodium Limits.

BACKGROUND: In June 2016, the Republic of South Africa introduced legislation for mandatory limits for the upper sodium content permitted in a wide range of processed foods. We assessed the sodium levels of packaged foods in South Africa during the one-year period leading up to the mandatory implementation date of the legislation. METHODS: Data on the nutritional composition of packaged foods was obtained from nutrition information panels on food labels through both in-store surveys and crowdsourcing by users of the HealthyFood Switch mobile phone app between June 2015 and August 2016. Summary sodium levels were calculated for 15 food categories, including the 13 categories covered by the sodium legislation. The percentage of foods that met the government's 2016 sodium limits was also calculated. RESULTS: 11,065 processed food items were included in the analyses; 1851 of these were subject to the sodium legislation. Overall, 67% of targeted foods had a sodium level at or below the legislated limit. Categories with the lowest percentage of foods that met legislated limits were bread (27%), potato crisps (41%), salt and vinegar flavoured snacks (42%), and raw processed sausages (45%). About half (49%) of targeted foods not meeting the legislated limits were less than 25% above the maximum sodium level. CONCLUSION: Sodium levels in two-thirds of foods covered by the South African sodium legislation were at or below the permitted upper levels at the mandatory implementation date of the legislation and many more were close to the limit. The South African food industry has an excellent opportunity to rapidly meet the legislated requirements.

A tool to help limit patients' sodium intake.

The average American consumes about 3400 mg/d of sodium, which is more than double the 1500 mg recommended by the American Heart Association.

Worldwide burden of gastric cancer in 2010 attributable to high sodium intake in 1990 and predicted attributable burden for 2030 based on exposures in 2010.

Assessing the impact that patterns of Na intake may have on gastric cancer will provide a more comprehensive estimation of Na reduction as a primary prevention approach. We aimed to estimate the proportion of gastric cancer cases that are attributable to Na intake above the recommendation by the WHO (≤2 g/d) throughout the world in 2010, as well as expected values for 2030. Population attributable fractions (PAF) were computed for 187 countries, using Na intakes in 1990 and 2010 and estimates of the association between Na intake and gastric cancer, assuming a time lag of 20 years. Median PAF ranged from 10·1% in low to 22·5 % in very high Human Development Index (HDI) countries in men (P<0·001) and from 7·2 to 16·6 %, respectively, among women (P<0·001). An increase in median PAF until 2030 is expected in most settings, except for countries classified as low HDI, in both sexes. High Na intakes account for a large proportion of gastric cancer cases, and proportions are expected to increase in almost all of the countries. Intensified efforts to diminish Na intake in virtually all populations are needed to further reduce gastric cancer burden.

Examination of food industry progress in reducing the sodium content of packaged foods in Canada: 2010 to 2013.

In 2010, as part of a national sodium reduction strategy, Canada published sodium reduction benchmark targets for packaged foods; however, no evaluation of this policy has occurred. The objective was to evaluate changes in the sodium content of packaged foods, identify categories reduced in sodium, and determine the proportion meeting Health Canada's sodium reduction benchmarks. This was a cross-sectional analysis of Canadian packaged foods in 2010 and 2013 (n = 10 487 and n = 15 394, respectively). Sodium content was obtained from the Nutrition Facts table. Overall, 16.2% of food categories had significantly reduced sodium levels. The greatest shifts in the distribution of sodium within food categories occurred in imitation seafood (mean ± SD, mg/100 g; 602 ± 50 to 444 ± 81, 26.2%, p = 0.002), condiments (1309 ± 790 to 1048 ± 620, 19.9%, p = 0.005), breakfast cereals (375 ± 26 to 301 ± 242, 19.7%, p = 0.001), canned vegetables/legumes (269 ± 156 to 217 ± 180, 19.3%, p < 0.001), plain chips (462 ± 196 to 376 ± 198, 18.6% p = 0.004), hot cereals (453 ± 141 to 385 ± 155, 15.0%, p = 0.011), meat analogues (612 ± 226 to 524 ± 177, 14.4%, p = 0.003), canned condensed soup (291 ± 62 to 250 ± 57, 14.1%, p = 0.003), and sausages and wieners (912 ± 219 to 814 ± 195, 10.7%, p = 0.012). The proportion of foods meeting at least 1 of the 3 phases of the sodium reduction benchmark targets slightly increased (51.4% to 58.2%) and the proportion exceeding maximum benchmark levels decreased (25.2% to 20.8%). These data provide a critical evaluation of changes in sodium levels in the Canadian food supply. Although progress in reducing sodium in packaged foods is evident, the food industry needs to continue efforts in reducing the sodium in the foods they produce.

Comparison of nutrient intakes from two selected diet plans considered healthful versus the cutoff points for green lights as defined by the UK's multiple traffic light scheme.

This study compared nutrient intakes from 7-day menus for the US MyPlate and DASH Eating Plan versus the cutoff points for green lights defined by the UK's multiple traffic light (MTL) scheme. For both diets, the foods achieved green lights for saturated fat and salt, and for beverages for total fat, saturated fat and salt. The other nutrients achieved amber lights but were within the range of the two diets. By contrast, the MTL threshold for salt in beverages was outside the range of the diets. The values for salt in beverages in the MyPlate and Dash diet plans were 0.06±0.07 and 0.19±0.01 (s.d.) g/100 ml, which are both considerably lower compared with the cutoff of 0.3 g/100 ml for an MTL green light. Adjusting the green MTL threshold values to the median values for a healthful diet could help make MTL labelling a more valid way of helping consumers choose a healthful diet.

Unilever Nutrition Strategy and Examples in Asia.

Millions of people in Asia are facing challenges from undernutrition, obesity, and diet-related non-communicable diseases. Unilever, as a global food business, has a simple approach to nutrition strategy: 'better products' help people to enjoy 'better diets' and live 'better lives.' For 'Better Products,' Unilever strives to improve the taste and nutritional qualities of all our products. By 2020, we commit to double the proportion of our entire global portfolio meeting the highest nutrition standards, based on globally recognised dietary guidelines. Unilever sets a clear plan to achieve reduction of sodium, saturated fat, trans fat, sugar, and calories in our products. Unilever developed fortified seasoning and spread products in 2013 for Vietnam, Indonesia, and the Philippines in collaboration with government bodies to address nutrient deficiencies. For 'Better Diets and Better Lives,' Unilever uses targeted communication to raise awareness and promote behavior change for healthy lifestyles. We committed to full nutrition labeling on our food products by 2015. We contribute experience to science-based regional initiatives on product labeling as well as nutrient profiling. Unilever collaborated with international, regional and country bodies to promote consumer understanding and food accessibility on public health priorities such as proper salt consumption, healthier meals, and employee well-being programs. Looking ahead, we are continuing to improve the nutritional profile of our products as well as our communication to improve diets and lives. Collaboration between industry, government and public health organizations is needed to address complex diet and life style issues.

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.

Inaugural Maximum Values for Sodium in Processed Food Products in the Americas.

Reducing dietary salt/sodium is one of the most cost-effective interventions to improve population health. There are five initiatives in the Americas that independently developed targets for reformulating foods to reduce salt/sodium content. Applying selection criteria, recommended by the Pan American Health Organization (PAHO)/World Health Organization (WHO) Technical Advisory Group on Dietary Salt/Sodium Reduction, a consortium of governments, civil society, and food companies (the Salt Smart Consortium) agreed to an inaugural set of regional maximum targets (upper limits) for salt/sodium levels for 11 food categories, to be achieved by December 2016. Ultimately, to substantively reduce dietary salt across whole populations, targets will be needed for the majority of processed and pre-prepared foods. Cardiovascular and hypertension organizations are encouraged to utilize the regional targets in advocacy and in monitoring and evaluation of progress by the food industry.

Water and sodium in heart failure: a spotlight on congestion.

Despite all available therapies, the rates of hospitalization and death from heart failure (HF) remain unacceptably high. The most common reasons for hospital admission are symptoms related to congestion. During hospitalization, most patients respond well to standard therapy and are discharged with significantly improved symptoms. Post-discharge, many patients receive diligent and frequent follow-up. However, rehospitalization rates remain high. One potential explanation is a persistent failure by clinicians to adequately manage congestion in the outpatient setting. The failure to successfully manage these patients post-discharge may represent an unmet need to improve the way congestion is both recognized and treated. A primary aim of future HF management may be to improve clinical surveillance to prevent and manage chronic fluid overload while simultaneously maximizing the use of evidence-based therapies with proven long-term benefit. Improvement in cardiac function is the ultimate goal and maintenance of a "dry" clinical profile is important to prevent hospital admission and improve prognosis. This paper focuses on methods for monitoring congestion, and strategies for water and sodium management in the context of the complex interplay between the cardiac and renal systems. A rationale for improving recognition and treatment of congestion is also proposed.

Are reductions in population sodium intake achievable?

The vast majority of Americans consume too much sodium, primarily from packaged and restaurant foods. The evidence linking sodium intake with direct health outcomes indicates a positive relationship between higher levels of sodium intake and cardiovascular disease risk, consistent with the relationship between sodium intake and blood pressure. Despite communication and educational efforts focused on lowering sodium intake over the last three decades data suggest average US sodium intake has remained remarkably elevated, leading some to argue that current sodium guidelines are unattainable. The IOM in 2010 recommended gradual reductions in the sodium content of packaged and restaurant foods as a primary strategy to reduce US sodium intake, and research since that time suggests gradual, downward shifts in mean population sodium intake are achievable and can move the population toward current sodium intake guidelines. The current paper reviews recent evidence indicating: (1) significant reductions in mean population sodium intake can be achieved with gradual sodium reduction in the food supply, (2) gradual sodium reduction in certain cases can be achieved without a noticeable change in taste or consumption of specific products, and (3) lowering mean population sodium intake can move us toward meeting the current individual guidelines for sodium 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.

Stakeholder discussion to reduce population-wide sodium intake and decrease sodium in the food supply: a conference report from the American Heart Association Sodium Conference 2013 Planning Group.

BACKGROUND: A 2-day interactive forum was convened to discuss the current status and future implications of reducing sodium in the food supply and to identify opportunities for stakeholder collaboration. METHODS AND RESULTS: Participants included 128 stakeholders engaged in food research and development, food manufacturing and retail, restaurant and food service operations, regulatory and legislative activities, public health initiatives, healthcare, academia and scientific research, and data monitoring and surveillance. Presentation topics included scientific evidence for sodium reduction and public health policy recommendations; consumer sodium intakes, attitudes, and behaviors; food technologies and solutions for sodium reduction and sensory implications; experiences of the food and dining industries; and translation and implementation of sodium intake recommendations. Facilitated breakout sessions were conducted to allow for sharing of current practices, insights, and expertise. CONCLUSIONS: A well-established body of scientific research shows that there is a strong relationship between excess sodium intake and high blood pressure and other adverse health outcomes. With Americans getting >75% of their sodium from processed and restaurant food, this evidence creates mounting pressure for less sodium in the food supply. The reduction of sodium in the food supply is a complex issue that involves multiple stakeholders. The success of new technological approaches for reducing sodium will depend on product availability, health effects (both intended and unintended), research and development investments, quality and taste of reformulated foods, supply chain management, operational modifications, consumer acceptance, and cost. The conference facilitated an exchange of ideas and set the stage for potential collaboration opportunities among stakeholders with mutual interest in reducing sodium in the food supply and in Americans' diets. Population-wide sodium reduction remains a critically important component of public health efforts to promote cardiovascular health and prevent cardiovascular disease and will remain a priority for the American Heart Association.