24-Hour Urinary Sodium and Potassium Excretion and Cardiovascular Risk.

BACKGROUND: The relation between sodium intake and cardiovascular disease remains controversial, owing in part to inaccurate assessment of sodium intake. Assessing 24-hour urinary excretion over a period of multiple days is considered to be an accurate method. METHODS: We included individual-participant data from six prospective cohorts of generally healthy adults; sodium and potassium excretion was assessed with the use of at least two 24-hour urine samples per participant. The primary outcome was a cardiovascular event (coronary revascularization or fatal or nonfatal myocardial infarction or stroke). We analyzed each cohort using consistent methods and combined the results using a random-effects meta-analysis. RESULTS: Among 10,709 participants, who had a mean (±SD) age of 51.5±12.6 years and of whom 54.2% were women, 571 cardiovascular events were ascertained during a median study follow-up of 8.8 years (incidence rate, 5.9 per 1000 person-years). The median 24-hour urinary sodium excretion was 3270 mg (10th to 90th percentile, 2099 to 4899). Higher sodium excretion, lower potassium excretion, and a higher sodium-to-potassium ratio were all associated with a higher cardiovascular risk in analyses that were controlled for confounding factors (P≤0.005 for all comparisons). In analyses that compared quartile 4 of the urinary biomarker (highest) with quartile 1 (lowest), the hazard ratios were 1.60 (95% confidence interval [CI], 1.19 to 2.14) for sodium excretion, 0.69 (95% CI, 0.51 to 0.91) for potassium excretion, and 1.62 (95% CI, 1.25 to 2.10) for the sodium-to-potassium ratio. Each daily increment of 1000 mg in sodium excretion was associated with an 18% increase in cardiovascular risk (hazard ratio, 1.18; 95% CI, 1.08 to 1.29), and each daily increment of 1000 mg in potassium excretion was associated with an 18% decrease in risk (hazard ratio, 0.82; 95% CI, 0.72 to 0.94). CONCLUSIONS: Higher sodium and lower potassium intakes, as measured in multiple 24-hour urine samples, were associated in a dose-response manner with a higher cardiovascular risk. These findings may support reducing sodium intake and increasing potassium intake from current levels. (Funded by the American Heart Association and the National Institutes of Health.).

Salt reduction policy for out of home sectors: a supplementary document for the salt reduction strategy to prevent and control non-communicable diseases (NCDS) in Malaysia 2021-2025.

Cardiovascular diseases (CVDs) are the major cause of death among Malaysians. Reduction of salt intake in populations is one of the most cost-effective strategies in the prevention of CVDs. It is very feasible as it requires low cost for implementation and yet could produce a positive impact on health. Thus, salt reduction initiatives have been initiated since 2010, and two series of strategies have been launched. However, there are issues on its delivery and outreach to the target audience. Further, strategies targeting out of home sectors are yet to be emphasized. Our recent findings on the perceptions, barriers and enablers towards salt reduction among various stakeholders including policy-makers, food industries, food operators, consumers and schools showed that eating outside of the home contributed to high salt intake. Foods sold outside the home generally contain a high amount of salt. Thus, this supplementary document is being proposed to strengthen the Salt Reduction Strategy to Prevent and Control Non-communicable Diseases (NCDs) for Malaysia 2021-2025 by focussing on the strategy for the out-of-home sectors. In this supplementary document, the Monitoring, Awareness and Product (M-A-P) strategies being used by the Ministry of Health (MOH) are adopted with a defined outline of the plan of action and indicators to ensure that targets could be achieved. The strategies will involve inter-sectoral and multi-disciplinary approaches, including monitoring of salt intake and educating consumers, strengthening the current enforcement of legislation on salt/sodium labelling and promoting research on reformulation. Other strategies included in this supplementary document included reformulation through proposing maximum salt targets for 14 food categories. It is hoped that this supplementary document could strengthen the current the Salt Reduction Strategy to Prevent and Control NCDs for Malaysia 2021-2025 particularly, for the out-of-home sector, to achieve a reduction in mean salt intake of the population to 6.0 g per day by 2025.

Sodium content targets for pre-packaged foods, China: a quantitative study and proposal.

Objective: To determine the contribution of pre-packaged foods to population sodium intake in China, and to propose sodium content targets for food subcategories used for the World Health Organization's (WHO's) global sodium benchmarks. Methods: The impact of four different approaches to reducing the sodium content of pre-packaged foods on population sodium intake was estimated using data from national databases covering the nutrient content and ingredients of 51 803 food products and food consumption by 15 670 Chinese adults. We recategorized food products using a food categorization framework developed for WHO's global sodium benchmarks and adapted for China-specific foods. Findings: Pre-packaged foods, including condiments, contributed 1302.5 mg/day of sodium intake per adult in 2021, accounting for 30.1% of population sodium intake in China. Setting maximum sodium content levels using a 90th-percentile target would reduce sodium intake from pre-packaged foods by 96.2 mg/day, corresponding to a 1.9% reduction in population intake. Using the 75th-percentile, a fixed 20% reduction and WHO benchmark targets would further reduce intake by 262.0 mg/day (5.2% population intake), 302.8 mg/day (6.0% population intake) and 701.2 mg/day per person (13.9% population intake), respectively. Maximum sodium content levels based on revised 20% reduction targets were proposed because they should result in substantial and acceptable reductions in sodium content for most food subcategories: overall sodium intake would decline by 305.0 mg/day per person, and population intake by 6.1%. Conclusion: This study provides the scientific rationale for government policy on setting targets for food sodium content in China. Simultaneous action on discretionary salt use should also be taken.

Perceptions, barriers and enablers on salt reduction in the out-of-home sectors in Malaysia (MySaltOH) from the perspective of street food vendors, caterers and consumers.

OBJECTIVE: To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers. DESIGN: A qualitative study involving twenty-two focus group discussions and six in-depth interviews was conducted, recorded and transcribed verbatim. An inductive thematic analysis approach was employed to analyse the data. SETTING: Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online. PARTICIPANTS: Focus group discussions were conducted among twenty-three street food vendors, twenty-one caterers and seventy-six consumers of various eateries. In-depth interviews were conducted among two street food vendors and four caterers, individually. RESULTS: Consumers and food operators perceived a high-salt intake within Malaysia's out-of-home food sectors. Food operators emphasised the necessity for a comprehensive salt reduction policy in the out-of-home sector involving all stakeholders. Consumers faced limited awareness and knowledge, counterproductive practices among food operators and challenges in accessing affordable low-Na food products, whereas food operators faced the lack of standardised guidelines and effective enforcement mechanisms and uncooperative consumer practices. Both groups expressed that food quality and price of salt were also the barriers, and they advocated for awareness promotion, enhanced regulation of manufactured food products and stricter enforcement targeting vendors. Consumers also suggested promoting and recognising health-conscious food premises, whereas food operators suggested on knowledge enhancement tailored to them, strategies for gaining consumers acceptance and maintaining food quality. CONCLUSIONS: These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia's out-of-home sectors.

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.

Sodium content of restaurant dishes in China: a cross-sectional survey.

BACKGROUND: Sodium intake in China is extremely high and eating in restaurants is increasingly popular. Little research has explored the sodium level of restaurant dishes. The present study aims to assess the content and sources of sodium in Chinese restaurants. METHODS: Cross-sectional data were obtained from the baseline survey of the Restaurant-based Intervention Study (RIS) in 2019. A total of 8131 best-selling restaurant dishes with detailed recipes from 192 restaurants in China were included. Sodium content per 100 g and per serving were calculated according to the Chinese Food Composition Table. The proportion of restaurant dishes exceeding the daily sodium reference intake level in a single serving and the major sources of sodium were determined. RESULTS: Median sodium content in restaurant dishes were 487.3 mg per 100 g, 3.4 mg per kcal, and 2543.7 mg per serving. For a single serving, 74.9% of the dishes exceeded the Chinese adults' daily adequate intake for sodium (AI, 1500 mg per day), and 62.6% of dishes exceeded the proposed intake for preventing non-communicable chronic diseases (PI, 2000 mg per day). Cooking salt was the leading source of sodium in Chinese restaurant dishes (45.8%), followed by monosodium glutamate (17.5%), food ingredients (17.1%), soy sauce (9.4%), and other condiments/seasonings (10.2%). More types of salted condiments/seasonings use were related to higher sodium level. CONCLUSIONS: The sodium levels in Chinese restaurant dishes are extremely high and variable. In addition to cooking salt, other salted condiments/seasonings also contribute a large proportion of sodium. Coordinated sodium reduction initiatives targeting the main sources of sodium in restaurant dishes are urgently needed.

Salt reduction to prevent hypertension: the reasons of the controversy.

There is a causal relationship between dietary salt intake and blood pressure. A reduction in salt intake from the current world average of ∼10 g/day to the WHO recommended level of <5 g/day, lowers blood pressure and reduces the risk of cardiovascular disease and all-cause mortality. However, a few cohort studies have claimed that there is a J-shaped relationship between salt intake and cardiovascular risk, i.e. both high and low salt intakes are associated with an increased risk. These cohort studies have several methodological problems, including reverse causality, and inaccurate and biased estimation of salt intake, e.g. from a single spot urine sample with formulas. Recent studies have shown that the formulas used to estimate salt intake from spot urine cause a spurious J-curve. Research with inappropriate methodology should not be used to refute the robust evidence on the enormous benefits of population-wide reduction in salt intake. Several countries, e.g. Finland, the UK, have successfully reduced salt intake, which has resulted in falls in population blood pressure and deaths from stroke and ischaemic heart disease. Every country should develop and implement a coherent, workable strategy to reduce salt intake. Even a modest reduction in salt intake across the whole population will lead to a major improvement in public health, along with huge cost-savings to the healthcare service.

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.

Comment on Hogas et al. Salt, Not Always a Cardiovascular Enemy? A Mini-Review and Modern Perspective. Medicina 2022, 58, 1175.

Hogas et al. recently published their perspective on dietary salt in a mini review [...].

Impact of color-coded and warning nutrition labelling schemes: A systematic review and network meta-analysis.

BACKGROUND: Suboptimal diets are a leading risk factor for death and disability. Nutrition labelling is a potential method to encourage consumers to improve dietary behaviour. This systematic review and network meta-analysis (NMA) summarises evidence on the impact of colour-coded interpretive labels and warning labels on changing consumers' purchasing behaviour. METHODS AND FINDINGS: We conducted a literature review of peer-reviewed articles published between 1 January 1990 and 24 May 2021 in PubMed, Embase via Ovid, Cochrane Central Register of Controlled Trials, and SCOPUS. Randomised controlled trials (RCTs) and quasi-experimental studies were included for the primary outcomes (measures of changes in consumers' purchasing and consuming behaviour). A frequentist NMA method was applied to pool the results. A total of 156 studies (including 101 RCTs and 55 non-RCTs) nested in 138 articles were incorporated into the systematic review, of which 134 studies in 120 articles were eligible for meta-analysis. We found that the traffic light labelling system (TLS), nutrient warning (NW), and health warning (HW) were associated with an increased probability of selecting more healthful products (odds ratios [ORs] and 95% confidence intervals [CIs]: TLS, 1.5 [1.2, 1.87]; NW, 3.61 [2.82, 4.63]; HW, 1.65 [1.32, 2.06]). Nutri-Score (NS) and warning labels appeared effective in reducing consumers' probability of selecting less healthful products (NS, 0.66 [0.53, 0.82]; NW,0.65 [0.54, 0.77]; HW,0.64 [0.53, 0.76]). NS and NW were associated with an increased overall healthfulness (healthfulness ratings of products purchased using models such as FSAm-NPS/HCSP) by 7.9% and 26%, respectively. TLS, NS, and NW were associated with a reduced energy (total energy: TLS, -6.5%; NS, -6%; NW, -12.9%; energy per 100 g/ml: TLS, -3%; NS, -3.5%; NW, -3.8%), sodium (total sodium/salt: TLS, -6.4%; sodium/salt per 100 g/ml: NS: -7.8%), fat (total fat: NS, -15.7%; fat per 100 g/ml: TLS: -2.6%; NS: -3.2%), and total saturated fat (TLS, -12.9%; NS: -17.1%; NW: -16.3%) content of purchases. The impact of TLS, NS, and NW on purchasing behaviour could be explained by improved understanding of the nutrition information, which further elicits negative perception towards unhealthful products or positive attitudes towards healthful foods. Comparisons across label types suggested that colour-coded labels performed better in nudging consumers towards the purchase of more healthful products (NS versus NW: 1.51 [1.08, 2.11]), while warning labels have the advantage in discouraging unhealthful purchasing behaviour (NW versus TLS: 0.81 [0.67, 0.98]; HW versus TLS: 0.8 [0.63, 1]). Study limitations included high heterogeneity and inconsistency in the comparisons across different label types, limited number of real-world studies (95% were laboratory studies), and lack of long-term impact assessments. CONCLUSIONS: Our systematic review provided comprehensive evidence for the impact of colour-coded labels and warnings in nudging consumers' purchasing behaviour towards more healthful products and the underlying psychological mechanism of behavioural change. Each type of label had different attributes, which should be taken into consideration when making front-of-package nutrition labelling (FOPL) policies according to local contexts. Our study supported mandatory front-of-pack labelling policies in directing consumers' choice and encouraging the food industry to reformulate their products. PROTOCOL REGISTRY: PROSPERO (CRD42020161877).

Labelling changes in response to a tax on sugar-sweetened beverages, United Kingdom of Great Britain and Northern Ireland.

OBJECTIVE: To evaluate the changes in sugar and energy labelling of carbonated sugar-sweetened soft drinks after the implementation of a tax on sugar-sweetened drinks in the United Kingdom of Great Britain and Northern Ireland. METHODS: We visited nine main supermarkets before (May 2014) and after (April 2018) the tax came into effect and obtained data from product packaging and nutrition information panels of carbonated sugar-sweetened soft drinks. We used the paired t-test to assess differences in sugar and energy content of the same products between 2014 and 2018. FINDINGS: We obtained data from 166 products in 2014 and 464 products in 2018, of which 83 products were the same in both years. Large variations in stated sugar content were found between the different carbonated sugar-sweetened soft drinks in both 2014 and 2018 for all products and for the 83 products. The mean sugar content of the 83 products decreased by 42% between 2014 and 2018, from 9.1 g/100 mL (standard deviation, SD: 3.3) to 5.3 g/100 mL (SD: 3.5; P < 0.001). The mean energy content decreased by 40%, from 38 kcal/100 mL (SD: 13) in 2014 to 23 kcal/100 mL (SD: 15) in 2018 (P < 0.001). CONCLUSION: The significant decreases in the labelling of sugar and energy content of carbonated sugar-sweetened soft drinks after the levy came into effect suggest this tax has been effective. The sugar content of drinks still varied considerably in 2018, suggesting further reductions in sugar content of these drinks is possible. The levy thresholds should be reduced and the tax increased to drive further reformulation of soft drinks to reduce their sugar content.

Urinary sodium is positively associated with urinary free cortisol and total cortisol metabolites in a cross-sectional sample of Australian schoolchildren aged 5-12 years and their mothers.

High Na intake and chronically elevated cortisol levels are independently associated with the development of chronic diseases. In adults, high Na intake is associated with high levels of urinary cortisol. We aimed to determine the association between urinary Na and K and urinary cortisol in a cross-sectional sample of Australian schoolchildren and their mothers. Participants were a sample of Australian children (n 120) and their mothers (n 100) recruited through primary schools. We assessed Na, K, free cortisol and cortisol metabolites in one 24 h urine collection. Associations between 24 h urinary electrolytes and 24 h urinary cortisol were assessed using multilevel mixed-effects linear regression models. In children, urinary Na was positively associated with urinary free cortisol (ß=0·31, 95 % CI 0·19, 0·44) and urinary cortisol metabolites (ß=0·006, 95 % CI 0·002, 0·010). Positive associations were also observed between urinary K and urinary free cortisol (ß=0·65, 95 % CI 0·23, 1·07) and urinary cortisol metabolites (ß=0·02, 95 % CI 0·03, 0·031). In mothers, urinary Na was positively associated with urinary free cortisol (ß=0·23, 95 % CI 0·01, 0·50) and urinary cortisol metabolites (ß=0·008, 95 % CI 0·0007, 0·016). Our findings show that daily Na and K intake were positively associated with cortisol production in children and their mothers. Investigation of the mechanisms involved and the potential impact of Na reduction on cortisol levels in these populations is warranted.

Salt and sugars content of breakfast cereals in the UK from 1992 to 2015.

OBJECTIVE: To study the salt and sugars content of breakfast cereals sold in the UK between 1992 and 2015. DESIGN: Cross-sectional surveys on salt and sugars content collected from the nutrition information panel of breakfast cereals in 1992, 2004, 2006, 2009, 2012 and 2015. SETTING: All major UK retailers operating at that moment in time (approximately ten). SUBJECTS: The salt and sugars content was collected from product packaging and the nutrition information panels. RESULTS: Cereals consistently surveyed across all five years (n22) showed a significant reduction in salt content of 47 % (P<0·001). Sugars content of breakfast cereals (n 15), however, did not show a significant change; 25·65 g/100 g in 1992 and 22·45 g/100 g in 2015 (P=0·170). There was a large variation in salt and sugars content between different categories and within the same type of category. CONCLUSIONS: The study shows the progressive reduction in salt content of breakfast cereals in the UK since 2004 as a result of the successful salt reduction programme, particularly the setting of incremental salt targets. Further reductions in salt content need to be made as cereals remain a major contributor to salt intake. Sugars content, however, has been consistently high due to the lack of a sugar reduction strategy. The research demonstrates that the sugars content of breakfast cereals in the UK is of concern, particularly in children's breakfast cereals, with a typical serving (30 g) containing a third of a 4-6-year-old's maximum daily recommendation (19 g/d) for free sugars intake in the UK. More can and should be done to reformulate, with an urgent need to set incremental sugar reduction targets.

Labelling completeness and sodium content of packaged foods in India.

OBJECTIVE: To estimate the proportion of products meeting Indian government labelling regulations and to examine the Na levels in packaged foods sold in India. DESIGN: Nutritional composition data were collected from the labels of all packaged food products sold at Indian supermarkets in between 2012 and 2014. Proportions of products compliant with the Food Safety Standards Authority of India (FSSAI) regulations and labelled with Na content, and mean Na levels were calculated. Comparisons were made against 2010 data from Hyderabad and against the UK Department of Health (DoH) 2017 Na targets. SETTING: Eleven large chain retail stores in Delhi and Hyderabad, India. SUBJECTS: Packaged food products (n 5686) categorised into fourteen food groups, thirty-three food categories and ninety sub-categories. RESULTS: More packaged food products (43 v. 34 %; P<0·001) were compliant with FSSAI regulations but less (32 v. 38 %; P<0·001) reported Na values compared with 2010. Food groups with the highest Na content were sauces and spreads (2217 mg/100 g) and convenience foods (1344 mg/100 g). Mean Na content in 2014 was higher in four food groups compared with 2010 and lower in none (P<0·05). Only 27 % of foods in sub-categories for which there are UK DoH benchmarks had Na levels below the targets. CONCLUSIONS: Compliance with nutrient labelling in India is improving but remains low. Many packaged food products have high levels of Na and there is no evidence that Indian packaged foods are becoming less salty.

24-h urinary sodium excretion is associated with obesity in a cross-sectional sample of Australian schoolchildren.

Emerging evidence indicates that dietary Na may be linked to obesity; however it is unclear whether this relationship is independent of energy intake (EI). The aim of this study was to assess the association between Na intake and measures of adiposity, including BMI z score, weight category and waist:height ratio (WHtR), in a sample of Australian schoolchildren. This was a cross-sectional study of schoolchildren aged 4-12 years. Na intake was assessed via one 24-h urine collection. BMI was converted to age- and sex-specific z scores, and WHtR was used to define abdominal obesity. In children aged ≥8 years, EI was determined via one 24-h dietary recall. Of the 666 children with valid urine samples 55 % were male (average age 9·3 (sd 1·8) years). In adjusted models an additional 17 mmol/d of Na was associated with a 0·10 higher BMI z score (95 % CI 0·07, 0·13), a 23 % (OR 1·23; 95 % CI 1·16, 1·31) greater risk of being overweight/obese and a 15 % (OR 1·15; 95 % CI 1·09, 1·23) greater risk of being centrally obese. In the subsample of 8-12-year-old children (n 458), adjustment for EI did not markedly alter the associations between Na and adiposity outcomes. Using a robust measure of daily Na intake we found a positive association between Na intake and obesity risk in Australian schoolchildren, which could not be explained by total energy consumption. To determine whether this is a causal relationship, longitudinal studies, with high-quality measures of Na and EI, are required.

Salt and sugar: their effects on blood pressure.

Both dietary salt and sugar are related to blood pressure (BP). The evidence for salt is much stronger, and various types of studies have consistently shown that salt is a major cause of raised BP, and a reduction from the current intake of ≈ 9-12 g/day in most countries of the world to the recommended level of 5-6 g/day lowers BP in both hypertensive and normotensive individuals, in men and women, in all age groups and in all ethnic groups. Countries such as Finland and the UK that have successfully reduced salt intake have demonstrated a reduction in population BP and cardiovascular mortality, with major cost savings to the health service. The mechanisms whereby salt raises BP are not fully understood. The traditional concepts focus on the tendency for an increase in extracellular fluid volume. Increasing evidence suggests that small increases in plasma sodium may play an important role. There are several other factors that also increase BP, one of which is added sugars. The current high intake of added sugars increases obesity which, in turn, raises BP. Recent studies also suggest that added sugars, particularly those in soft drinks, may have a direct effect on BP. However, the relationship between soft drink consumption and BP could be, at least partially, mediated by the effect of salt intake on increasing soft drink consumption. Actions to reduce salt and sugar intake across the whole population will have major beneficial effects on health along with major cost savings.