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THE NEW ZEALAND
MEDICAL JOURNAL
Journal of the New Zealand Medical Association
NZMJ 15 April 2011, Vol 124 No 1332; ISSN 1175 8716 Page 1 of 9
URL: http://www.nzma.org.nz/journal/124-1332/4607/ ©NZMA
World Salt Awareness Week: more action needed in
New Zealand
Rachael M McLean, Jim I Mann, Janet Hoek
World Salt Awareness Week ran from 21 to 27 March 2011. Increasing attention to
the detrimental health effects of a high dietary salt intake has led to substantial public
health campaigns in the United Kingdom, New York, Finland, Japan, and Canada.
Indeed, recent modelling indicates that salt reduction is likely to be one of the most
cost-effective population public health interventions for chronic disease reduction
available.
US estimates suggest reducing Americans’ salt intake by as little as 3 grams per day
could reduce annual deaths by 44,000 and save between $10 billion and $24 billion in
annual healthcare costs. The benefits with respect to cardiovascular disease outcomes
for the US are estimated to be similar to population tobacco or obesity reduction
strategies.
1
Similarly, estimates suggest that among low and middle income countries
salt reduction would be at least as effective as tobacco control for reducing deaths
from cardiovascular disease.
2
Modelling work undertaken New Zealand in 2003 estimated that a population
reduction of salt intake of 2.5 grams per day would lead to an overall decrease of 1.0
mmHg in the mean population systolic blood pressure (producing a 4-6 mmHg
decrease in systolic blood pressure in adults ≥65 years of age), and would result in a
total reduction of 282 deaths and 2613 years of life lost per year from heart disease
and stroke.
3
Health consequences of a high salt intake
There is now a compelling body of evidence that demonstrates a linear dose response
relationship between dietary salt intake and blood pressure.
4
Large epidemiological
observational studies such as INTERSALT (a cross-sectional study which examined
the association between 24-hour urinary sodium excretion and blood pressure in 32
countries around the world) showed that populations such as the Yanomamo of Brazil
with very low dietary salt intake demonstrated significantly lower blood pressure than
populations with higher dietary salt intakes. These ‘low-salt’ populations also showed
no increase in blood pressure with age, thereby challenging the view that increasing
blood pressure is an inevitable consequence of ageing.
5
A Cochrane Collaboration systematic review and meta-analysis of randomised trials
demonstrated that for adults, a reduction of sodium intake by at least 40 mmol (or 2.3
grams salt per day) would lead to an average reduction in blood pressure of 5/3
mmHg for hypertensive and 2/1 mmHg for normotensive adults. Furthermore, the
authors estimated that if these changes were to be achieved at a population level this
would reduce stroke deaths by approximately 14% and ischaemic heart disease deaths
by 9% in adults with hypertension, and 6% and 4% respectively in those with normal
blood pressure.
6
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A meta-analysis of controlled trials investigating salt intake and blood pressure in
children and adolescents (≤18 years) showed that a modest reduction in sodium intake
would significantly reduce blood pressure.
7
While there is some evidence that some
individuals and population groups (such as African Americans and obese adults) are
more ‘salt sensitive’ than others,
8
the overwhelming evidence shows that that the vast
majority of both normotensive and hypertensive people will respond to a reduction in
dietary sodium intake with a small reduction in blood pressure.
4
There is little evidence to support the notion that only the few ’salt sensitive’
individuals need to monitor their dietary sodium intake. The combination of a diet
high in potassium and low in sodium such as the Dietary Approaches to Stop
Hypertension or DASH diet (a diet high in fruits, vegetables and low-fat dairy
products, and low in saturated and total fat) is particularly effective in reducing blood
pressure in adults with hypertension.
9
Evidence also links dietary salt intake directly with adverse cardiovascular outcomes.
A systematic review and meta-analysis of prospective studies published 1966–2008
showed that a diet high in salt is associated with significantly increased risk of stroke
and total cardiovascular disease.
10
While much of this effect is likely to be mediated by elevated blood pressure,
increasingly, dietary salt intake is recognised as having direct adverse cardiovascular
effects such as impaired endothelial function and arterial vascular tone.
11,12
In addition
to cardiovascular effects, a high dietary salt intake is also associated with increased
risk of gastric cancer, kidney disease and osteoporosis.
4
Nutrient reference values
New Zealand and Australia have jointly determined nutrient reference values for
sodium with the recommended upper level of intake (UL) for adults set at
2300mg/day (equivalent to 5.8 grams salt per day). For children and adolescents the
UL has been extrapolated at a lower level based on proportional energy intake.
The New Zealand guidelines state that for some people (older or overweight people
and those with existing hypertension) a lower ‘suggested dietary target’ of 1600 mg
sodium per day or 4 grams salt per day would be beneficial.
13
US dietary guidelines
released early 2011 now recommend a population upper level of intake of 1500
milligrams per day of sodium or 3.75 grams salt.
8
‘Salt’ and ‘sodium’
Since the majority (around 90%) of dietary sodium is in the form of sodium chloride
or salt,
14
many public health initiatives refer to ‘salt’ rather than ‘sodium’. The use of
the word 'sodium' on food labels however can cause some confusion, especially since,
to convert sodium to salt, consumers must multiply the amount of sodium by
approximately 2.5 (so that 1 gram of sodium converts to approximately 2.5 grams of
salt).
Consequently many consumers have difficulty understanding the relationship between
‘sodium’ and ‘salt’. For instance, a study of 226 New Zealand shoppers in 2006
showed that only 10% were able to correctly identify the value for the sodium UL
when expressed as salt. Although 67% of participants reported that they monitored
NZMJ 15 April 2011, Vol 124 No 1332; ISSN 1175 8716 Page 3 of 9
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their salt intake, only 2% were able to correctly identify the amount of salt in a can of
baked beans, based on information on sodium content in the Nutrition Information
Panel. The majority of participants believed that the terms ‘salt’ and ‘sodium’ were
interchangeable.
15
Estimates of salt intake
New Zealanders have an estimated salt intake of around 9 grams per day, which is
consistent with similar countries around the world. This estimate is based on 24 hour
urine sodium measurements from adults 16 years and older in Milton in the 1970s and
1980s,
16
and further 24 hour urinary samples from a range of participants in Dunedin,
Waikato and Taranaki from 1993–1998.
17
Estimates of salt intake for minority population groups such as Māori and Pacific
people within New Zealand are lacking. Alarmingly, population estimates in many
Asian countries are substantially higher than 9 grams, raising the possibility that
Asian populations within New Zealand may also have particularly high salt intakes.
Recent estimates suggest a mean population dietary salt intake of 11 grams per day in
Japan, 12 grams per day in China, 8.5 grams per day in an urban south Indian
population, and 11–13 grams per day in the Republic of Korea.
18–20
While a 24 hour urinary sodium is considered the ‘gold standard’ estimate of dietary
salt intake,
21
dietary surveys are useful to indicate the key sources of sodium in the
diet. In Western countries it is generally accepted that around 75% of dietary sodium
intake comes from processed foods, 10–15% from sodium naturally inherent in foods,
10% is discretionary added in cooking and at the table, and around 1% comes from
drinking water.
14,22
Other populations show different patterns of sodium intake. In China, it is estimated
that around 78% of sodium intake is added during cooking, and in Japan the main
sources of sodium include soy sauce, fish and soups with around 10% as added salt
during cooking.
18,23
New Zealand research shows that for all age groups, bread is the leading source of salt
intake from processed foods, with processed meats (such as bacon and sausages)
sauces, breakfast cereals, instant meals (including meat pies and instant noodles) and
baked and dairy products also contributing substantially to dietary salt intake.
3,24,25
Uses of salt in processed food
In modern food processing, salt performs three main functions: taste enhancement,
preservation, and processing functions. Salting is one of the earliest methods of food
preservation. Salt slows microbial growth by reducing water activity at particular
concentrations. The use of salt as a preservative is particularly important in meat and
meat products, pickled vegetables, fermented products (e.g. soy sauce), sauces, and
chilled foods.
26
In baked products such as bread and cakes, salt delays mould formation thereby
extending shelf life. In processing, salt is reported to improve texture and succulence
by its ability to retain water in products such as sausages.
26
It also allows producers to
add weight (and therefore value) to meat products, while maintaining that a product is
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‘natural’.
27
In bread and other baked products, salt helps to control the rate of yeast
fermentation, influencing texture.
26
Although risks to microbiological food safety are a potential barrier to salt reduction
in some processed foods, surveys show that sodium content in similar foods varies
greatly, so it should be feasible to reduce salt content in several foods without
compromising food safety, providing the lowest level of salt already in use remains
inhibitory.
28
Modern processing and refrigeration also contribute to preservation and processing
functions thereby enabling further salt reduction. In addition to providing a salty taste,
salt blocks unpleasant tastes such as bitterness and flavours related to food spoilage,
and it enhances the effect of other more palatable flavours such as meaty flavours.
Salt moderates the sweetness of sugars used in breakfast cereals and confectionary.
26
Humans have a natural preference for salty tastes, thought to be mediated by specific
salt receptors on the tongue, however preference for salty foods is related to salt
intake over the previous 8–12 weeks, and humans adjust their salt preferences to
either a high salt or low salt diet accordingly.
29
A gradual reduction in salt concentration is therefore unlikely to be noticed by
consumers,
30
making this a sensible way of achieving population wide gains in salt
reduction.
Salt reduction strategies:
Since around three-quarters of dietary salt intake comes from that already in
processed foods interventions with the greatest impact would change food
composition, and thus consumers’ food supply.
22
Reduction of discretionary salt used
at home in cooking and at the table has limited potential to result in significant overall
reductions in salt intake, and risks lowering dietary iodine intake because much of the
salt used at home is iodised.
Reducing the amount of salt in processed food would have a greater impact in terms
of population salt reduction, and would probably not substantially reduce New
Zealanders’ iodine intake. This is because apart from bread, which has contained
iodised salt since 2009, most of the salt in processed foods non-iodised. However,
monitoring of population iodine status, particularly in childhood, will need to be
maintained.
If iodine status is threatened by salt reduction a number of alternatives could be
considered such as:
• Increasing the concentration of iodine in iodised salt
• Mandating the use of iodised salt in all processed foods, not just bread
• Making iodisation of other staple foods such as oil, bread, drinking water,
sugar and animal feeds mandatory.
23,31
Since 2003 the UK Food Standards Agency (FSA) has undertaken a salt reduction
strategy that can be seen as a model for the rest of the world. It appears to have been a
success with a 10% reduction in mean population salt intake from an average of 9.5
grams/day salt in 2000–2001 to 8.6 grams/day in 2008.
32
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Key elements of the FSA strategy include setting a population salt intake target of an
average of 6 grams per day, working with the food industry to reformulate processed
food to contain less salt, making improvements to food labelling which include
introduction of a traffic light labelling scheme, and conducting a public awareness
campaign.
33
New Zealand would benefit greatly from a co-ordinated government-led population
salt reduction strategy, similar to that undertaken in the United Kingdom. Based on
the available international evidence the following strategies should be implemented:
• Reformulation of processed foods can reduce dietary salt intake for the whole
population without requiring people to alter their dietary habits, thereby
achieving maximum population impact. If done gradually consumers are
unlikely to notice any difference in taste.
30
In New Zealand, the National Heart Foundation has worked with the food
industry in this area for several years, first with the award winning Project
Target 450 which has reduced the amount of sodium in many low-cost and
high-volume breads to 450 milligrams sodium per 100 grams,
34
and more
recently with project HeartSAFE.
35
However, more could be achieved by
setting sodium concentration targets across a wide range of foods, as has been
done in the United Kingdom.
36
Modelling has shown that the setting of a wide
range of targets relating to specific foods is the most effective and cost-
effective method of population dietary salt reduction.
37,38
• Raising consumer awareness has been an important part of many successful
salt reduction strategies. Dietary advice on its own is unlikely to be either
effective or cost-effective,
38
and indeed has largely failed to reduce sodium
intake on a population level in the past,
39
However as part of a comprehensive
salt reduction programme raising public awareness of the need for dietary salt
reduction has a number of potential benefits. Food industry representatives
have in the past cited lack of consumer demand for low salt products as
barriers to reformulation, pointing out that “public tastes continue to dictate
the marketplace”.
39,p4–8
Increased consumer demand for lower salt products is likely to encourage
industry to produce and promote low salt options, as well as reformulate
mainstream products. An evaluation of the UK FSA public awareness
programme indicated changes to self-reported behaviour from consumers such
as cutting down on their salt intake and increased attention to food labels for
sodium/salt levels.
33
Although it is unclear to what extent these self reported
changes have translated to altered purchasing and eating behaviours,
population surveys show a reduction in dietary sodium intake of around 10%
over the period of the salt reduction strategy as a whole.
32
Healthcare professionals have an ideal opportunity to promote salt reduction,
especially when engaging patients in discussions about cardiovascular risk and
blood pressure.
• Labelling of processed food needs to be improved in order to help consumers
identify the amount of salt in foods. Nutrition labelling has been mandatory in
New Zealand since 2002, and includes reference to sodium content. More
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recently, several food manufacturers have voluntarily introduced front of pack
Percent Daily Intake (PDI) labels to complement the mandatory Nutrition
Information Panels.
40
However, the PDI for sodium is based on upper level of
daily sodium intake for adults of 2300 milligrams/day rather than the
suggested dietary target of 1600 milligrams per day.
41
The adult reference
values are used in calculating the PDI for all foods, even those which are
marketed to children, despite the upper limit for children under 14 years of age
being lower than the recommended adult levels. This is potentially misleading
for consumers, particularly those shopping for children.
• In 2007, the UK FSA introduced a voluntary front of pack labelling scheme
that uses multiple traffic lights (MTL) to communicate fat, saturated fat, salt
and sugar levels of a food. The MTL uses the word ‘salt’ rather than ‘sodium’
and there are set criteria for salt level in foods.
42
International research
suggests that visual devices such as the MTL, which enable consumers to
assess nutritional composition without the need to process detailed numerical
information, may enable consumers to better differentiate between high and
low sodium foods.
43
Nutrition claims such as ‘light’, ‘reduced salt’, ‘low salt’
may also enhance understanding of sodium content.
44
In New Zealand a
product can be labelled ‘low salt’ if it contains less than 120mg/100g of
sodium, and labelled ‘reduced salt’ if the food has at least 25% less sodium
than the comparative reference food.
Current New Zealand legislation prohibits health claims relating to disease
prevention (other than for folate). However, Food Standards Australia New
Zealand (FSANZ) is developing a Nutrition, Health and Related Claims
Standard (Proposal P293) that will outline requirements for nutritional content
claims, general level health claims and high-level health claims.
45
It is
important to investigate how health claims could influence consumer
purchasing behaviour with respect to claims regarding sodium and salt prior to
their implementation in New Zealand.
• Although further research specific to New Zealand context is pending we
should not delay implementation. Further research could then form the basis of
monitoring and evaluation of dietary salt intake in the future.
Many multinational food companies are developing and implementing sodium
reduction strategies in response to public health initiatives overseas. Now is the ideal
time for New Zealand maximise the opportunities presented by these international salt
reduction activities. International evidence shows that a comprehensive public health
programme to reduce population dietary salt intake is one of the most effective and
cost-effective public health interventions available.
A co-ordinated, government-led salt reduction programme should include: setting
sodium concentration targets across a wide range of foods; raising public awareness
of the health consequences of a high salt intake and how to reduce their own salt
intake; and improvements to food labelling. Ongoing monitoring of New Zealanders’
salt intake and salt content in foods should support this. Cardiovascular disease
remains one of the leading causes of death and disability in New Zealand. An
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effective salt reduction strategy could reduce morbidity from heart disease and stroke,
reduce healthcare costs, and save hundreds of lives a year.
Competing interests: None.
Author information: Rachael M McLean, Senior Research Fellow, Edgar National
Centre for Diabetes and Obesity Research, Department of Medicine, University of
Otago, Dunedin; Jim I Mann, Professor, Edgar National Centre for Diabetes and
Obesity Research, Department of Medicine, University of Otago, Dunedin;
Janet Hoek, Professor, Department of Marketing, University of Otago, Dunedin
Acknowledgement: RM is supported by a Health Research Council of New Zealand
Clinical Research Training Fellowship.
Correspondence: Rachael McLean, Senior Research Fellow, Edgar National Centre
for Diabetes and Obesity Research, Department of Medicine, University of Otago,
Dunedin, New Zealand. Email: rachael.mclean@otago.ac.nz
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