Why is salt reduction important?
Excessive salt intake is a major global public health concern as it accounts for a considerable proportion of the burden of noncommunicable diseases such as high blood pressure and cardiovascular diseases, especially coronary heart disease (CHD) and stroke. There is a clear link between high salt intake and high blood pressure; likewise there is conclusive scientific evidence that reduction of sodium consumption reduces blood pressure. High blood pressure is a major risk factor for both stroke and CHD, resulting in excess deaths and severe disability among survivors. Even a small (1 g per person per day) reduction in salt intake will reduce deaths from strokes and heart attacks by more than 7% in each country that takes the appropriate measures to achieve this.
Salt reduction is a very cost-effective public health policy. For example, in the United Kingdom it was estimated that for a total campaign cost of £15 million to reduce daily salt intake, £1.5 billion per year would be saved in health care costs.1
Salt consumption in the Region
WHO recommends no more than 2 g of sodium (equivalent to 5 g of salt) per day. Approximately 95% of sodium is consumed in the form of salt. Data collected from the Eastern Mediterranean Region show that the average daily salt consumption in most countries is estimated or measured to be around 10 g per person per day, double the amount recommended by WHO; intake in a few countries is even well above this level In most countries in the Region, bread alone accounts for up to 40% of the total dietary salt intake, with an average salt content varying from 0.28% to 1.52% according to the results of a rapid analysis study of the salt content of staple “flat” bread and other breads traditionally consumed in selected countries of the Region. Significant variations exist in the salt content of the same type of bread from one country to another, in addition to variations existing among different types of bread within the same country. The highest average salt content level observed in bread was in Morocco (1.47 g/100 g) contributing to about 50% of total dietary salt intake. The lowest average salt content levels were observed in the Lebanese bread in Jordan (0.42 g/100 g), Egypt (0.55 g/100 g), Qatar (0.52 g/100 g) and Lebanon (0.55 g/100 g), representing 12.3%, 19.3%, 14.8% and 18.3% of the total dietary salt intake based on 300 g of daily bread intake per person. Added salt during home cooking, food preparation and catering or upon eating is yet another considerable source of salt intake in the Region as it the consumption of salty food products, such as cheese, processed meat and tomato products and pickles.
Global salt reduction developments
With evidence showing that population-based salt reduction measures are very cost-effective in reducing the burden of noncommunicable diseases, such measures have been identified as among the ‘best buys’ for noncommunicable diseases. Best buys are cheap, feasible and culturally acceptable to implement in all health systems. The Political Declaration of the High-Level Meeting of the United Nations General Assembly on the Prevention and Control of Non-communicable Diseases, held in New York in September 2011 and attended by heads of states and governments, emphasized the importance of salt reduction as a key intervention to reduce the burden of noncommunicable diseases. Consequently, the 66th World Health Assembly endorsed a 30% relative reduction in mean population intake of salt by 2025. Reducing salt intake and meeting this goal is also crucial for achieving two other targets for 2025 also endorsed by the Assembly: a 25% relative reduction in the prevalence of raised blood pressure (defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg) and a 25% relative reduction in premature mortality from noncommunicable diseases.
Regional response
The Regional Committee for the Eastern Mediterranean in its Fifty-ninth and Sixtieth sessions in October 2012 and October 2013, respectively, adopted two resolutions (EM/RC59/R.2 and EM/RC60/R.4) concerning the implementation of the Political Declaration of the High-Level Meeting of the United Nations General Assembly on the Prevention and Control of Noncommunicable Diseases. Central to both resolutions is a regional framework for action to implement the Political Declaration with commitments by Member States to implement a set of strategic interventions including salt reduction.
In this regard, the WHO Regional Office for the Eastern Mediterranean convened a series of multistakeholder technical meetings focusing on population salt reduction strategies that culminated in: (1) developing and publishing the regional protocol on 24-hour urinary sodium and iodine measurements, which was used as a guide to aid research efforts in the Region, (2) supporting a network of regional research institutions – in Egypt, Iran, Jordan, Lebanon, Morocco, Tunisia and United Arab Emirates – in conducting the 24-hour urinary sodium excretion as the gold standard for assessing a person's dietary sodium intake, (3) developing a policy guidance with recommended actions for Member States to lower national salt intake and death rates from high blood pressure and stroke in the Eastern Mediterranean Region (summarized in Box 1) and (4) setting up a regional monitoring mechanism to monitor progress and maintain accountability for results at the national and regional levels.
Research institutions, including WHO Collaborating Centres, in several countries are producing nationally representative data on population salt intake using 24-hour urinary sodium excretion, salt content of commonly consumed foods, and food consumption patterns. This research will provide crucial data to inform policy and monitor the impact of programmes and interventions.
National progress scaled up
A few Member States are currently taking active steps based on the policy guidance and recommended actions on salt reduction. Kuwait gradually reduced the salt content of bread through its public bread supplier that provides the majority of the market need for bread by 20% in one year as follows: 10% reduction in the first 6 months of 2013, followed by another 10% reduction in the following months in 2013. This is an important public health achievement. Moreover, Kuwait is currently revising its salt standard for cheese and is establishing national targets for upper limit of salt content in 13 types of mostly consumed cheeses.
Qatar has reduced the salt content in bread by 10% since early 2014 through its main public bread supplier that provides nearly a third of the market need for bread. A further 10% reduction in salt content of the same bread is planned for by end of 2014. The Islamic Republic of Iran has adopted legislative approaches towards salt reduction in a number of products, including establishing maximum levels of salt in highly consumed canned foods, such as tomato paste, and salty snacks.
Other Member States are in the process of preparing draft legislation on salt reduction (Bahrain) and/or revising existing legislation to develop benchmarks for salt content of highly consumed foods like cheese (Jordan and Kuwait). In others (Egypt, Islamic Republic of Iran, Jordan, Kuwait, Oman and Qatar), multisectoral national committees have been established with an authority to strategize and monitor implementation of salt reduction activities.
Box 1 Summary of recommended actions to lower national salt intake and death rates from high blood pressure and stroke in the Eastern Mediterranean Region
Phase 1: January 2014 – focus on bread production
- Establish a national taskforce on salt reduction representing key stakeholders and partners.
- Achieve a 10% reduction of salt/sodium in staple bread within 3–4 months which will reduce salt intake by about 0.5 g per day in the whole population.
- Establish salt standards for compliance by all bakers.
- Promote compliance by linking government flour/bread subsidies and other incentives to bakers’
- Mandate the use of iodized salt in local and imported food to ensure adequate maintenance of the population’s iodine status.
- Identify the top five other food contributors to salt/sodium in the national diet other than bread.
- Review and progressively revise national food standards for bread so as to achieve a 30% reduction in salt/sodium in bread from current levels over an 18-month period.
- Establish national groups to obtain population-based food intake data, a laboratory group to measure the salt content of specified foods and a national group for monitoring salt intake using 24 h urine measurements.
Phase 2: June 2014
- Confirm progressive salt changes in national bread production.
- Government establishments to start reducing salt content in all food served on their premises by 10% every 6 months over a period of 2 years.
Phase 3: January 2015
- Confirm government-based initiatives and compliance with further 10% reduction in salt levels.
- Engage major national businesses and all caterers to help lower salt intakes.
- Conduct a public education campaign focused primarily on caterers and those providing food.
- Engage with general businesses to encourage them to contribute to reduce salt in the food provided in their canteens.
- Educate caterers and those responsible for home cooking.
Source: http://www.emro.who.int/nutrition/strategy/salt-policy-statement.html
The way forward
The reduction of salt intake in populations is everybody’s business and is a crucial intervention for protecting and promoting the health of people in the Eastern Mediterranean Region. Salt reduction is best achieved through serious and sustained multidimensional and multisectoral approaches through a step by step process that follows the policy guide and recommended actions developed by WHO in consultation with Member States. All countries must now implement measures, guided by a national multisectoral strategy and plan, to reduce salt intake at the population level. There is a need to monitor compliance by Member States with the agreed-upon set of actions to scale up interventions and measure impact at both national and regional levels while sharing evidence on what really works in our Region. There is also a greater need to engage civil society, youth and the media, particularly in building awareness and advocacy efforts around salt reduction and policy impact measurement. Based on the technical consultations and feedback by Member States, WHO is currently working on a series of steps to support countries in adopting other cost-effective measures, such as developing guidance on legislative approaches to salt reduction and examining evidence towards implementing taxes on salt and high salt foods as international experiences, namely from Hungary and Portugal, support the effectiveness of such measures. WHO also intends to generate evidence on the economic cost of salt reduction and on addressing the technological barriers and food safety concerns in producing quality bread with low salt content.
- PH25 prevention of cardiovascular disease: costing report. Implementing NICE guidance. London: National Institute for Health and Care Excellence; 2010 (http://guidance.nice.org.uk/PH25/CostingReport/pdf/English, accessed 18 May 2014)
- Guideline: Sodium intake for adults and children. Geneva: World Health Organization; 2012 (www.who.int/nutrition/publications/guidelines/sodium_intake_printversion.pdf, accessed 18 May 2014).
- Global status report on noncommunicable diseases 2010. Geneva: World Health Organization; 2011 (www.who.int/nmh/publications/ncd_report_full_en.pdf, accessed 18 May 2014)
- United Nations. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases. Resolution adopted by the General Assembly, New York, 19 September 2011 (A/Res/66/2).
