The potential for current sodium and potassium production to support a global switch to the use of potassium-enriched salt: a desktop research study.

OBJECTIVE: Switching regular salt (sodium chloride) for salt enriched with potassium chloride (25% potassium chloride, 75% sodium chloride) has been shown to reduce blood pressure and the risk of cardiovascular diseases. We sought to define the potential for current production of sodium chloride and potassium chloride to support a global switch to the use of potassium-enriched salt. DESIGN: We summarised data from geological surveys, government reports and trade organisations describing the global production and supply of sodium chloride and potash (the primary source of potassium chloride) and compared this to potential requirements for potassium-enriched salt. SETTING: Global. SUBJECTS: N/A. RESULTS: Approximately 280 million tonnes of sodium chloride were produced in 2020 with China and the United States the main producers. Global production of potash from which potassium chloride is extracted was about 44 million tonnes with Canada, Belarus, Russia and China providing 77% of the world's supply. There were 48 countries in which potassium-enriched salt is currently marketed with 79 different brands identified. Allowing for loss of salt between manufacture and consumption, a full global switch from regular salt to potassium-enriched salt would require about 9.7 million tonnes of sodium chloride to be replaced with 9.7 million tonnes of potassium chloride annually. CONCLUSIONS: Significant up-scaling of the production of potassium chloride and the capacity of companies able to manufacture potassium-enriched salt, as well as a robust business case for the switch to potassium chloride, would be required.

Individual and total sugar contents of street foods in Malaysia - Should we be concerned?

Street foods are often of poor nutritional quality with high sugar content, in which the overconsumption of sugar is associated with obesity. However, sugar content information on local street foods is scarce. Thus, the individual and total sugar contents of 94 types of street foods in Malaysia were analysed. Compared to snacks and main meals, desserts contained the highest amounts of sugar, sucrose, fructose, glucose, and maltose. Sucrose was predominant in 90% desserts, 79.3% snacks, and 68.6% main meals. Most desserts (93.3%) contained medium to high sugar content (≥5 g to >15 g/100 g), while 82.9% main meals and 65.5% snacks had low sugar content. When comparing the sugar contents of 39 foods with other local databases, 58.3% main meals, 55.6% desserts, and 33.3% snacks contained either significantly (p < 0.05) higher or lower sugar contents. Consumers can identify low and high-sugar foods, and policymakers can review health priorities to combat obesity.

The contribution of sodium reduction and potassium increase to the blood pressure lowering observed in the Salt Substitute and Stroke Study.

The Salt Substitute and Stroke Study (SSaSS) demonstrated significant reductions in systolic blood pressure (SBP), and the risk of stroke, major cardiovascular events and total mortality with the use of potassium-enriched salt. The contribution of sodium reduction versus potassium increase to these effects is unknown. We identified four different data sources describing the association between sodium reduction, potassium supplementation and change in SBP. We then fitted a series of models to estimate the SBP reductions expected for the differences in sodium and potassium intake in SSaSS, derived from 24-h urine collections. The proportions of the SBP reduction separately attributable to sodium reduction and potassium supplementation were calculated. The observed SBP reduction in SSaSS was -3.3 mmHg with a corresponding mean 15.2 mmol reduction in 24-h sodium excretion and a mean 20.6 mmol increase in 24-h potassium excretion. Assuming 90% of dietary sodium intake and 70% of dietary potassium intake were excreted through urine, the models projected falls in SBP of between -1.67 (95% confidence interval: -4.06 to +0.73) mmHg and -5.33 (95% confidence interval: -8.58 to -2.08) mmHg. The estimated proportional contribution of sodium reduction to the SBP fall ranged between 12 and 39% for the different models fitted. Sensitivity analyses assuming different proportional urinary excretion of dietary sodium and potassium intake showed similar results. In every model, the majority of the SBP lowering effect in SSaSS was estimated to be attributable to the increase in dietary potassium rather than the fall in dietary sodium.

Strengthening national salt reduction strategies using multiple methods process evaluations: case studies from Malaysia and Mongolia.

OBJECTIVE: To understand the extent to which national salt reduction strategies in Malaysia and Mongolia were implemented and achieving their intended outcomes. DESIGN: Multiple methods process evaluations conducted at the mid-point of strategy implementation, guided by theoretical frameworks. SETTING: Malaysia (2018-2019) and Mongolia (2020-2021). PARTICIPANTS: Desk-based reviews of related documents, interviews with key stakeholders (n 12 Malaysia, n 10 Mongolia), focus group discussions with health professionals in Malaysia (n 43) and health provider surveys in Mongolia (n 12). RESULTS: Both countries generated high-quality local evidence about salt intake and levels in foods and culturally specific education resources. In Malaysia, education and reformulation activities were delivered with moderate dose (quantity) but reach among the population was low. Within 5 years, Mongolia implemented education among schools, health professionals and food producers on salt reduction with high reach, but with moderate dose (quantity) and reach among the general population. Both countries faced challenges in implementing legislative interventions (mandatory salt labelling and salt limits in packaged foods) and both could improve the scaling up of their reformulation and education activities. CONCLUSIONS: In the first half of Malaysia's and Mongolia's strategies, both countries generated necessary evidence and education materials, mobilised health professionals to deliver salt reduction education and achieved small-scale reformulation in foods. Both subsequently should focus on implementing regulatory policies and achieving population-wide reach and impact. Process evaluations of existing salt reduction strategies can help strengthen intervention delivery, aiding achievement of WHO's 30 % reduction in salt intake by 2025 target.

Switching the World's Salt Supply-Learning from Iodization to Achieve Potassium Enrichment.

Sodium is an essential dietary component, but excess sodium intake can lead to high blood pressure and an increased risk of cardiovascular disease. Many national and international bodies, including the World Health Organization, have advocated for population-wide sodium reduction interventions. Most have been unsuccessful due to inadequate sodium reduction by food industry and difficulties in persuading consumers to add less salt to food. Recent research highlights potassium-enriched salt as a new, feasible, acceptable, and scalable approach to reducing the harms caused by excess sodium and inadequate potassium consumption. Modeling shows that a global switch from regular salt to potassium-enriched salt has the potential to avert millions of strokes, heart attacks, and premature deaths worldwide each year. There will be many challenges in switching the world's salt supply to potassium-enriched salt, but the success of universal salt iodization shows that making a global change to the manufacture and use of salt is a tractable proposition. This in-depth review of universal salt iodization identified the importance of a multisectoral effort with strong global leadership, the support of multilateral organizations, engagement with the salt industry, empowered incountry teams, strong participation of national governments, understanding the salt supply chain, and a strategic advocacy and communication plan. Key challenges to the implementation of the iodization program were costs to government, industry, and consumers, industry concerns about consumer acceptability, variance in the size and capabilities of salt producers, inconsistent quality control, ineffective regulation, and trade-related regulatory issues. Many of the opportunities and challenges to universal salt iodization will likely also be applicable to switching the global salt supply to iodized and potassium-enriched salt.

The impact of community-based food access strategies in high-income countries: a systematic review of randomised controlled trials.

OBJECTIVES: Some geographic regions in high-income countries (HIC), including Australia, have poor healthy food access and a high burden of diet-related chronic disease. Scalable and sustainable strategies to strengthen community food systems have the potential to address these inequities. To inform future interventions in regions with poor healthy food access in Sydney, Australia, and beyond, we systematically reviewed randomised controlled trials of community-based food access interventions in HIC, to identify effects on dietary behaviours and health outcomes. METHODS: Four electronic databases were searched. Studies involving community-based healthy food access strategies (solely or combined with education/behaviour change) and measuring effects on dietary behaviours and/or health outcomes were identified. Data on dietary behaviours, health outcomes and intervention descriptions were extracted, and the risk of bias was assessed. RESULTS: Seven studies met inclusion criteria, with most conducted in the US (n = 6). Intervention strategies included food pantry-based interventions (n = 2), mobile produce markets (n = 2) and community farms (n = 3). Most interventions (n = 6, 85%) incorporated educational and/or behavioural change aspects. All studies measured fruit and vegetable (F&V) intake, with nearly all (n =6, 85%) reporting significant beneficial effects. CONCLUSION: Preliminary evidence in our synthesis demonstrates that multicomponent community-based food system interventions promise to improve F&V intake in regions of HICs. Recommendations for improving future evaluations are identified to build evidence for policymakers and urban planners to enact upstream and downstream strategies to strengthen community healthy food, particularly in geographic regions with the greatest health inequities.

Current food labelling practices in online supermarkets in Australia.

BACKGROUND: Food product labelling can support consumer decision-making. Several food product labels (nutrition information panels (NIPs), ingredients lists, allergen declarations and country-of-origin) are mandated for physical product packaging in Australia, with a voluntary front-of-pack nutrition labelling system, Health Star Ratings (HSRs), also available. However, labelling requirements are not explicitly extended to online settings and the extent to which this information is available in these increasingly important food environments has not been assessed. METHODS: Data from all individual food product pages was collected from the online stores of the two dominant supermarket retailers in Australia using automated web scraping in April-May 2022 (n = 22,077 products collected). We assessed the proportion of pages displaying NIPs, ingredients, allergens, country-of-origin and HSRs after excluding products ineligible to display the respective label. We also assessed whether HSRs were differentially available for higher- (healthier) and lower-scoring (less healthy) products, with HSR scores drawn from a comprehensive Australian food composition database, FoodSwitch. A manual inspection of randomly selected product pages (n = 100 for each label type per supermarket), drawn from products displaying the relevant label, was conducted to assess whether the labels were immediately visible to users (i.e. without scrolling or clicking). Differences in labelling prevalence and visibility were compared using chi-squared tests. RESULTS: Across both supermarkets, country-of-origin labelling was almost complete (displayed on 93% of food product pages), but NIPs (49%), ingredients (34%) and allergens (53%) were less frequently displayed. HSRs were infrequently displayed (14% across both supermarkets) and more likely to be applied to higher-scoring products (22% on products with ≥ 3.5HSR v 0.4% on products with < 3.5HSR, p < 0.001). One supermarket was far more likely to make NIPs (100% v 2%, p < 0.001), ingredients (100% v 19%, p < 0.001) and allergens (97% v 0%, p < 0.001) information immediately visible, though the other made HSRs more apparent (22% v 75%, p < 0.001). Both supermarkets displayed country-of-origin labels prominently (100% v 86%, p < 0.001). CONCLUSIONS: Food product labelling varies in online supermarkets in Australia overall and between supermarkets, while the design of online stores resulted in differences in labelling visibility. The near-complete display of country-of-origin labels and differential application of HSRs to higher-scoring products may reflect their use as marketing tools. Our findings highlight an urgent need for food labelling regulations to be updated to better account for online retail food environments.

Protocol for a randomized controlled trial of medically tailored meals compared to usual care among individuals with type 2 diabetes in Australia.

BACKGROUND: 'Food is medicine' strategies aim to integrate food-based nutrition interventions into healthcare systems and are of growing interest to healthcare providers and policy makers. 'Medically Tailored Meals' (MTM) is one such intervention, which involves the 'prescription' by healthcare providers of subsidized, pre-prepared meals for individuals to prevent or manage chronic conditions, combined with nutrition education. OBJECTIVE: This study will test the efficacy of an MTM program in Australia among participants with type 2 diabetes (T2D) and hyperglycemia, who experience difficulties accessing and eating nutritious food. METHODS: This study will be a two-arm parallel trial (goal n = 212) with individuals randomized in a 1:1 ratio to a MTM intervention group or a control group (106 per arm). Over 26 weeks, the intervention group will be prescribed 20 MTM per fortnight and up to 3 sessions with an accredited dietitian. Controls will continue with their usual care. The primary outcome is glycated hemoglobin (HbA1c, %) and secondary outcomes include differences in blood pressure, blood lipids and weight, all measured at 26 weeks. Process and economic data will be analyzed to assess the feasibility, acceptability, scalability, and cost-effectiveness of the intervention. Recruitment commenced in the first quarter of 2023, with analyses and results anticipated to be available by March 2025. DISCUSSION: Few randomized controlled trials have assessed the impact of MTM on clinical outcomes. This Australian-first trial will generate robust data to inform the case for sustained, large-scale implementation of MTM to improve the management of T2D among vulnerable populations. ANZCTR: ACTRN12622000852752. PROTOCOL VERSION: Version 1.1, July 2023.

Outcomes of a state-wide salt reduction initiative in adults living in Victoria, Australia.

PURPOSE: To assess any effects of a state-wide sodium reduction intervention on sodium intake, sources of dietary sodium and discretionary salt use at a population level. METHODS: Data (24-h urinary sodium excretion, self-report survey, a 24-h dietary recall) were collected cross-sectionally at baseline (2016/2017) and follow-up (2020) from adults in Victoria, Australia. Intervention activities included consumer awareness advertising campaign, public debate generation via mass media, strengthening existing policy initiatives and supporting food innovation with industry. RESULTS: There were 339 participants at baseline and 211 at follow-up, with 144 and 90 of participants completing a 24-h dietary recall, respectively. There was no difference in adjusted 24-h urinary sodium excretion between baseline and follow-up (134 vs 131 mmol/24 h; p = 0.260). There were no differences in the percentage of participants adding salt during cooking (63% vs 68%; p = 0.244), adding salt at the table (34% vs 37%; p = 0.400) or regularly taking action to control salt/sodium intake (22% vs 21%; p = 0.793). There were large differences in the quantity of dietary sodium sourced from retail stores (57% vs 77%, p < 0.001), and less sodium was sourced from foods at fresh food markets (13% vs 2%; p ≤ 0.001) at follow-up. No large differences were apparent for foods with different levels of processing or for food groups. CONCLUSION: There was no clear population-level effect of the 4-year multi-component Victorian Salt Reduction Intervention on sodium intake with Victorian adults continuing to consume sodium above recommended levels. The findings indicate that more intensive and sustained efforts aiming at the retail and food industry with national level support are likely to be required to achieve a measurable improvement in sodium intake at a state level.

Changes in sodium levels in Australian packaged foods between 2014 and 2019: an interrupted time series analysis of the impact of the Victorian Salt Reduction Partnership's media advocacy strategy.

BACKGROUND: The Victorian Salt Reduction Partnership (VSRP) implemented a media advocacy strategy (intervention) to stimulate food manufacturers to reduce sodium levels across targeted Australian packaged foods between 2017 and 2019. This study assessed changes in sodium levels of targeted and non-targeted packaged foods during the intervention (2017 to 2019) compared to before the intervention (2014 to 2016) in Australia. METHODS: Annually collected branded-food composition data from 2014 to 2019 were used. Interrupted time series analyses was conducted to compare the trend in sodium levels in packaged foods during the intervention (2017-2019) to the trend in the pre-intervention period (2014-2016). The difference between these trends was derived to estimate the effect of the intervention. RESULTS: A total of 90,807 products were included in the analysis, of which 14,743 were targeted by the intervention. The difference in before and during intervention trends between targeted and non-targeted food categories was 2.59 mg/100 g (95% CI: -13.88 to 19.06). There was a difference in the pre-intervention slope (2014, 2015, 2016) and intervention slope (2017, 2018, 2019) for four of 17 targeted food categories. There was a decrease in sodium levels (mg/100 g) in one food category: frozen ready meals (-13.47; 95% CI: -25.40 to -1.53), and an increase in three categories: flat bread (20.46; 95% CI: 9.11 to 31.81), plain dry biscuits (24.53; 95% CI: 5.87 to 43.19), and bacon (44.54; 95% CI: 6.36 to 82.72). For the other 13 targeted categories, the difference in slopes crossed the line of null effect. CONCLUSIONS: The VSRP's media advocacy strategy did not result in a meaningful reduction in sodium levels of targeted packaged food products during the intervention years compared to trends in sodium levels before the intervention. Our study suggests media advocacy activities highlighting the differences in sodium levels in packaged food products and industry meetings alone are not sufficient to lower average sodium levels in packaged foods in the absence of government leadership and measurable sodium targets.

Do Food and Nutrition Policies in Ethiopia Support the Prevention of Non-Communicable Diseases through Population-Level Salt Reduction Measures? A Policy Content Analysis.

INTRODUCTION: Despite the importance of salt reduction to health outcomes, relevant policy adoption in Ethiopia has been slow, and dietary consumption of sodium remains relatively high. AIM: This analysis aims to understand the content and context of existing food-related policy, strategy, and guideline documents to identify gaps and potential opportunities for salt reduction in Ethiopia in the wider context of global evidence-informed best practice nutrition policy. METHODS: Policy documents relevant to food and noncommunicable diseases (NCDs), published between 2010 and December 2021, were identified through searches of government websites supplemented with experts' advice. Documentary analysis was conducted drawing on the 'policy cube' which incorporates three dimensions: (i) comprehensiveness of policy measures, which for this study included the extent to which the policy addressed the food-related WHO "Best Buys" for the prevention of NCDs; (ii) policy salience and implementation potential; and (iii) equity (including gender) and human rights orientation. RESULTS: Thirty-two policy documents were retrieved from government ministries, of which 18 were deemed eligible for inclusion. A quarter of these documents address diet-related "Best Buys" through the promotion of healthy nutrition and decreasing consumption of excess sodium, sugar, saturated fat, and trans-fats. The remainder focuses on maternal and child health and micronutrient deficiencies. All documents lack detail relating to budget, monitoring and evaluation, equity, and rights. CONCLUSIONS: This review demonstrates that the Government of Ethiopia has established policy frameworks highlighting its intention to address NCDs, but that there is an opportunity to strengthen these frameworks to improve the implementation of salt reduction programs. This includes a more holistic approach, enhanced clarification of implementation responsibilities, stipulation of budgetary allocations, and promoting a greater focus on inequities in exposure to nutrition interventions across population groups. While the analysis has identified gaps in the policy frameworks, further qualitative research is needed to understand why these gaps exist and to identify ways to fill these gaps.

Fatty Acid Composition of Selected Street Foods Commonly Available in Malaysia.

Despite growing evidence of increased saturated and trans fat contents in street foods, little is known about their fatty acid (FA) compositions. This study aimed to analyse the saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), and trans fatty acids (TFAs) content of 70 selected and most commonly available street foods in Malaysia. The street foods were categorised into main meals, snacks, and desserts. TFAs were not detected in any of the street foods. Descriptively, all three categories mainly contained SFAs, followed by MUFAs, and PUFAs. However, the one-way ANOVA testing showed that the differences between each category were insignificant (p > 0.05), and each FA was not significantly different (p > 0.05) from one to another. Nearly half of the deep-fried street foods contained medium to high SFAs content (1.7 g/100 g-24.3 g/100 g), while the MUFAs were also high (32.0-44.4%). The Chi-square test of association showed that the type of preparation methods (low or high fat) used was significantly associated (p < 0.05) with the number of SFAs. These findings provide valuable information about fat composition in local street foods for the Malaysian Food Composition Database and highlight the urgency to improve nutritional composition.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia.

OBJECTIVE: In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. DESIGN: Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. SETTING: Victoria, Australia. PARTICIPANTS: Children aged 4-12 years. RESULTS: Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. CONCLUSION: These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia.

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18-65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (-8% (95%CI -12, -3)) and that their child added salt at the table (-5% (95% -9, -0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact.

Estimated Dietary and Health Impact of the World Health Organization's Global Sodium Benchmarks on Packaged Foods in Australia: a Modeling Study.

BACKGROUND: In 2021, the World Health Organization (WHO) set sodium benchmarks for packaged foods to guide countries in setting feasible and effective sodium reformulation programs. We modeled the dietary and health impact of full compliance with the WHO's sodium benchmarks in Australia and compared it to the potential impact of Australia's 2020 sodium reformulation targets. METHODS: We used nationally representative data on food and sodium intake, sodium levels in packaged foods, and food sales volume to estimate sodium intake pre- and post-implementation of the WHO and Australia's sodium benchmarks for 24 age-sex groups. Using comparative risk assessment models, we then estimated the potential deaths, incidence, and disability-adjusted life years averted from cardiovascular disease, chronic kidney disease, and stomach cancer based on the reductions in sodium intake. RESULTS: Compliance with the WHO's sodium benchmarks for packaged foods in Australia could lower mean adult sodium intake by 404 mg/day, corresponding to a 12% reduction. This could prevent about 1770 deaths/year (95% uncertainty interval 1168-2587), corresponding to 3% of all cardiovascular disease, chronic kidney disease, and stomach cancer deaths in Australia, and prevent some 6900 (4603-9513) new cases, and 25 700 (17 655-35 796) disability-adjusted life years/year. Compared with Australian targets, the WHO benchmarks will avert around 3 and a half times more deaths each year (1770 versus 510). CONCLUSIONS: Substantially greater health impact could be achieved if the Australian government strengthened its current sodium reformulation program by adopting WHO's more stringent and comprehensive sodium benchmarks.

The nutritional profile of plant-based meat analogues available for sale in Australia.

AIM: To assess the nutritional quality of plant-based meat analogues in Australia, compared to equivalent meat products, and to assess levels of micronutrient fortification in meat analogues. METHODS: This cross-sectional study used nutrition composition data for products collected in 2021 from major supermarkets in Australia. Nutritional quality was assessed using the Health Star Rating, energy (kJ), protein (g), saturated fat (g), sodium (mg), total sugars (g), and fibre content (g) per 100 g, and level of food processing using the NOVA classification. Proportion of products fortified with iron, vitamin B12 and zinc were reported. Differences in health star rating and nutrients between food categories were assessed using independent t-tests. RESULTS: Seven hundred ninety products (n = 132 plant-based and n = 658 meat) across eight food categories were analysed. Meat analogues had a higher health star rating (mean 1.2 stars, [95% CI: 1.0-1.4 stars], p < 0.001), lower mean saturated fat (-2.4 g/100 g, [-2.9 to -1.8 g/100 g], p < 0.001) and sodium content (-132 mg/100 g, [-186 to -79 mg/100 g], p < 0.001), but higher total sugar content (0.7 g/100 g, [0.4-1.1 g/100 g], p < 0.001). Meat analogues and meat products had a similar proportion of ultra-processed products (84% and 89%, respectively). 12.1% of meat analogues were fortified with iron, vitamin B12 and zinc. CONCLUSION: Meat analogues generally had a higher health star rating compared with meat equivalents, however, the nutrient content varied. Most meat analogues were also ultra-processed and few are fortified with key micronutrients found in meat. More research is needed to understand the health impact of these foods.

Stakeholder perspectives on Nigeria's national sodium reduction program: Lessons for implementation and scale-up.

BACKGROUND: To reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions. METHODS: From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions. RESULTS: Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum. CONCLUSION: We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

Review of national nutrition standards with salt-related criteria for publicly funded institutions around the world.

CONTEXT: Creating healthy food environments through nutrition standards for publicly funded institutions (eg, schools, workplaces, and hospitals) provides an important opportunity to improve population diets. OBJECTIVE: This study aimed to identify countries with national nutrition standards for publicly funded institutions that included salt-related criteria and to describe and summarize these initiatives. DATA SOURCES: Peer-reviewed and grey literature was searched to December 2019, including MEDLINE, CENTRAL, Embase, TRoPHI, LILACS, Web of Science, Cochrane Public Health Group Specialised Register, and Effective Public Health Practice Project Database. In addition, a questionnaire was sent to country contacts and salt-reduction experts, and a targeted search on relevant government websites was conducted. DATA EXTRACTION: Key characteristics of the national nutrition standards for publicly funded institutions were extracted, including name, governance, institution type, implementation status, and details of food and nutrient criteria. DATA ANALYSIS: Nutrition standards were analyzed by World Health Organization region, World Bank income level, institution type, type of criteria, regulatory approach, and method of application. Sixty-six countries were identified as having national nutrition standards that included salt-related criteria for at least one publicly funded institution. Standards were more prevalent in the European Region, high-income countries, and schools compared to other regions, income levels, and institution types, respectively. Most standards were mandatory and contained nutrition criteria pertaining to both foods and nutrients. CONCLUSION: Nutrition standards have the potential to significantly improve diets, but there is considerable scope to develop and implement nutrition standards more effectively using the new World Health Organization Action Framework.