Evaluating the role of salt intake in achieving WHO NCD targets in the Eurasian Economic Union: A PRIME modeling study.

The World Health Organization has set clear global targets in reducing non-communicable disease mortality by 2030 in its sustainable development goals. This study models the number of deaths that could be averted if Eurasian Economic Union (EEU) member states met the target of reducing their population's current mean salt intake by 30% to achieve mortality reduction targets. Using the WHO Preventable Risk Integrated ModEl (PRIME), we modelled the mortality impact of reducing salt consumption by 30%, as well as according to WHO recommended levels (5 g/person/day), for the five member states of the EEU. PRIME models the number of averted deaths from reducing salt intake by applying established risk ratios to a given population. The baseline demographic and mortality data that are required to generate these estimates were obtained from the relevant government statistical bodies, and salt intake data were referenced from surveillance studies. Uncertainty intervals were generated using Monte Carlo simulation. If salt consumption was reduced by 30%, we estimate that there would have been 94,150 (95%UI: 47,329 to 137,131) fewer deaths due to cardiovascular disease in the EEU in the baseline year, with males and the elderly being more affected. If the WHO-recommended maximum salt intake of 5 g/day was achieved, a total of 193,155 (95%UI: 98,548 to 272,536) deaths would have been prevented. These findings underline the importance of incorporating effective policy changes to meet targets in reducing NCD mortality by one-third by 2030.

Projecting cardiovascular deaths averted due to trans fat policies in the Eurasian Economic Union.

OBJECTIVE: To demonstrate the potential impact on population health if policies designed to reduce population trans fatty acid (TFA) intake are successfully implemented in the Eurasian Economic Union (EAEU) in line with the WHO's guidelines to lower intake of TFA as a percentage of total energy intake to less than 1 %. DESIGN: A projection exercise was conducted to estimate reductions in CVD-related deaths in countries of the EAEU if TFA policies are implemented in the EAEU. Plausibly causal, annual effects (in %) of Denmark's TFA policy on the evolution of CVD mortality rates were applied to project the potential effects of recently announced TFA policies in Armenia, Belarus, Kazakhstan, Kyrgyzstan and the Russian Federation under three TFA exposure scenarios. SETTINGS: Member States of the EAEU: Armenia, Belarus, Kazakhstan, Kyrgyzstan and the Russian Federation. PARTICIPANTS: Data used for the projection exercise were based on estimates from natural experimental evidence from Denmark. National CVD mortality rates used were from WHO and the Organisation for Economic Cooperation and Development datasets. RESULTS: In all countries and in all scenarios, deaths averted were ≤ 5 deaths/100,000 in year 1 and rose in years 2 and 3. The highest projected impacts in the high-exposure scenario were seen in Kyrgyzstan (39 deaths/100 000), with the lowest occurring in Armenia (24 deaths/100 000). CONCLUSION: This study demonstrates the potential population health gains that can be derived from effective policies to reduce TFA in line with WHO guidance. Monitoring and surveillance systems are needed to evaluate the effectiveness of the TFA reduction policies in a national context.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam.

OBJECTIVE: To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC). DESIGN: Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy. SETTING: Argentina, Mongolia, South Africa and Vietnam. PARTICIPANTS: Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes. RESULTS: Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts. CONCLUSIONS: Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Availability, healthiness, and price of packaged and unpackaged foods in India: A cross-sectional study.

Background: Vulnerable populations are the most prone to diet-related disease. The availability, healthiness, and price of foods have established associations with diet-related disease in communities. However, data describing this in India are sparse, particularly in urban slums and rural areas. Aim: To quantify and compare availability, healthiness, and price of packaged and unpackaged foods and beverages in India, and to identify opportunities to improve diets and health of vulnerable populations. Methods: Nutrition data and price were collected on foods and beverages available at 44 stores in urban, urban slum, and rural areas in four states in India between May and August 2018. Healthiness was assessed using the Australasian Health Star Rating system and product retail prices were examined. Comparisons in the findings were made across state, community area type, and adherence to current and draft Indian food labeling regulations. Results: Packaged foods and beverages (n = 1443, 89%) were more prevalent than unpackaged (n = 172, 11%). Unpackaged products were healthier than packaged (mean Health Star Rating = 3.5 vs 2.0; p < 0.001) and lower in price (median price per 100 g/ml: 13.42 Indian rupees vs 25.70 Indian rupees; p < 0.001), a pattern observed across most community area types and states. 96% of packaged products were compliant with current Indian labeling regulations but only 23% were compliant with proposed labeling regulations. Conclusions: Unpackaged products were on average much healthier and lower in price than packaged foods and beverages. Food policies that support greater availability, accessibility and consumption of unpackaged foods, while limiting consumption of packaged foods, have enormous potential for sustaining the health of the Indian population.

Unpack the Salt: an evaluation of the Victorian Salt Reduction Partnership's media advocacy activities to highlight the salt content of different foods.

BACKGROUND: Australians are consuming almost double the recommended maximum salt intake. The Victorian Salt Reduction Partnership was established to coordinate efforts to reduce salt intake in the state of Victoria. As part of an intervention strategy, media advocacy strategies were used to raise public awareness and stimulate industry and government action on salt reduction. This study aimed to evaluate the Victorian Salt Reduction Partnership's media advocacy activities by determining the extent to which activities contributed to the overall strategy aims and the effectiveness of the activities in gaining media and industry engagement. METHODS: A framework for evaluating media advocacy strategies used in complex public health interventions was used to guide this evaluation. Media advocacy activities were monitored and documented throughout the intervention period. A content analysis of media release press statements was performed. Indicators of media coverage (media items, cumulative audience reach, advertising space rate) and food industry engagement (number of meetings, number and type of follow up actions) were tracked. RESULTS: Six media releases were issued between March 2017 and November 2018 on different processed food categories including breads, cooking sauces, ready meals, dips and crackers, processed meats and Asian-style sauces. Three main themes were identified in the qualitative analysis of the press statements: general information on salt and health, salt levels in foods, and calls to action for consumers, industry and/or government. These themes were aligned with the overall intervention strategy. Media items (print and online news, radio and TV) generated by each release ranged from 36 to 274, and cumulative audience reach (opportunities to see) ranged from 2.3 to 7.5 million Australians per release. One to three food manufacturers were met with per media release. CONCLUSIONS: Disseminating sodium-monitoring data through media releases can be used as a tool to gain access to the media and reach consumers with salt reduction messages, and to engage food manufacturers in discussions about salt reduction. Characteristics of media advocacy activities, including alignment with the overall strategy, and external factors outside the of control of the program implementers, can influence media and industry engagement. When planning future nutrition interventions that include media advocacy activities, internal and external factors impacting outcomes, should be considered, documented and evaluated.

The effectiveness, feasibility, and acceptability of low-sodium salts worldwide: An environmental scan protocol.

Excess sodium intake elevates blood pressure and risk for cardiovascular diseases. The use of low-sodium salts is a potentially cost-effective strategy to counter the rising global burden of cardiovascular diseases. This research aimed to understand the potential scale-up of low-sodium salt interventions by examining the availability of low-sodium salts globally, synthesizing evidence about the effectiveness of low-sodium salt interventions, and identifying the challenges and opportunities associated with implementing low-sodium salt interventions. This study consists of three parts. The first part is a systematic online search of low-sodium salts. The authors will use the advanced search functions of search engines and online shopping sites to execute the search. The second part is a systematic review of academic literature on the use of low-sodium salts. A meta-analysis will be performed to quantify the effectiveness of low-sodium salt interventions. The third part is key informant interviews to understand the challenges of implementing low-sodium salt interventions. Key informants will include policymakers, academic researchers, and salt industry representatives. The list of key informants will be generated through purposive sampling and snowball sampling based on the completed online search and the systematic review. The interview guides will be developed based on the RE-AIM (Reach, Effective, Adoption, Implementation, and Maintenance) framework. The study received ethics approval from the University of New South Wales Human Research Ethics Advisory Panel (HC190921). Findings will be disseminated with academics and policymakers through a peer-reviewed journal and conference presentations.

Assessing the Healthy Food Partnership's Proposed Nutrient Reformulation Targets for Foods and Beverages in Australia.

Non-communicable diseases (NCDs) are the leading cause of mortality and morbidity worldwide. Unhealthy diets are one of four main behavioral risk factors contributing to the majority of NCDs. To promote healthy eating and reduce dietary risks, the Australian Commonwealth Government established the Healthy Food Partnership (HFP). In 2018, the HFP consulted on proposed nutrient reformulation targets for 36 food categories to improve the overall quality of the food supply. This study assessed whether the proposed targets were feasible and appropriate. The HFP used a five-step approach to inform the proposed targets. We replicated and extended this approach using a different nutrient composition database (FoodSwitch). Products in FoodSwitch were mapped to the proposed HFP targets. The proportion of products meeting each target was calculated and the FoodSwitch data were compared with HFP data to determine whether the proposed target nutrient levels were appropriate or whether a more stringent target was feasible. Products from the FoodSwitch database (10,599) were mapped against the proposed HFP categories: 8434 products across 30 categories for sodium, 2875 products across seven categories for sugar, and 612 products across five categories for saturated fat. The analyses revealed that 14 of 30 proposed HFP targets for sodium, one of seven targets for sugar, and one of five targets for saturated fat were feasible and appropriate. For the remaining 26 reformulation targets, the results indicate that these target levels could be more stringent and alternative targets are proposed. The draft HFP targets are feasible but the majority are too conservative. If Australia is to meet its commitment to a 30 per cent reduction in the average population salt intake by 2025, these targets could be implemented as interim targets to be reached within two years. However, the opportunity exists to improve the food supply and strengthen the HFP's population health impact by adopting more ambitious and incremental targets. Reformulation programs should be prioritized and closely monitored as part of a coordinated, multi-faceted national food and nutrition strategy.

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.

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.

Know Your Noodles! Assessing Variations in Sodium Content of Instant Noodles across Countries.

Reducing salt intake is a cost-effective public health intervention to reduce the global burden of non-communicable disease (NCDs). Ultra-processed foods contribute ~80% of dietary salt in high income countries, and are becoming prominent in low-middle income countries. Instant noodle consumption is particularly high in the Asia Pacific region. The aim of this study was to compare the sodium content of instant noodles sold worldwide to identify potential for reformulation. Analysis was undertaken for 765 instant noodle products from 10 countries using packaged food composition databases of ultra-processed foods compiled by the Global Food Monitoring Group (GFMG) and national shop survey data. Sodium levels were high and variable, within and between countries. Instant noodles in China had the highest mean sodium content (1944 mg/100 g; range: 397-3678/100 g) compared to New Zealand (798 mg/100 g; range: 249-2380 mg/100 g). Average pack size ranged from 57 g (Costa Rica) to 98 g (China). The average packet contributed 35% to 95% of the World Health Organization recommended daily salt intake of <5 g. Forty-one percent of products met the Pacific Island (PICs) regional sodium targets, 37% met the South Africa 2016 targets, and 62% met the UK 2017 targets. This study emphasises a need for stronger regulation and closer monitoring to drive rigorous reformulation of salt in ultra-processed foods.