Health impact assessment of salt reduction in bread in Portugal: a pilot study

Hypertension is a risk factor for cardiovascular diseases, which can be caused by excessive salt intake. In Portugal, one of the main foods to contribute to ingestion of salt is bread. Thus, a voluntary Protocol was signed between stakeholders with the aim to reduce salt content in bread by 2021. Herein, a retrospective HIA was carried out to assess the impact in blood pressure (BP) after this agreement. In order to find average values of salt intake and BP in Portuguese population, national surveys were used. Also, estimates of BP reduction and its size effects were calculated based upon meta-analysis data. It is expected that salt intake will be reduced mostly in individuals with low educational level, men, aged between 65-74 years old and residents in South region of Portugal. Results in hypertensive patients indicate that a higher effect on BP will occur in the same profile of individuals, except age (between 55 and 64 years old). However, the estimated effect is very low for all groups, suggesting that the Protocol will contribute to modest health gains. Complementary measures supported by HIA studies need to be adopted to actively promote salt intake reduction and effectively prevent hypertension.

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Innovative equipments to monitor and control salt usage during culinary

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.583 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

C Gonçalves ◽

O Pinho ◽

P Padrão ◽

T Silva-Santos ◽

S Abreu ◽

...

Keyword(s):

Salt Intake ◽

Salt Content ◽

Clinical Intervention ◽

Health Impact ◽

Salt Reduction ◽

Salt Consumption ◽

Catering Industry ◽

And Control ◽

The Impact ◽

At Home

Abstract Issue In Portugal, most of the salt consumed comes from the salt added during preparation/cooking. Therefore, it is urgent to introduce mechanisms to allow the quantification of the salt in foods, and the salt added during culinary. Description of the Problem To tackle salt reduction, we considered: having a portable and user-friendly instrument that measure salt content of foods; and controlling the amount of salt added to foods during culinary, assessing its impact on health. The first project was SALT QUANTI (co-funded by NORTE 2020), promoted by a consortium between EVOLEO Technologies and the University of Porto (finished in September 2018, duration 18 months); its major deliverable was to obtain a prototype of a portable device and the analytical procedure that enabled the analysis of salt content in foods/meals produced in catering kitchens, in less than 5 minutes. The second project was iMC SALT (supported by FCT, Grant POCI-01-0145-FEDER-029269), started in July 2018 (duration 36 months), aiming to develop prototypes for controlling the amount of salt added to foods during culinary, at home and catering, according international recommendations; one clinical intervention to assess the impact on health of the prototype at home is underway. Results The SALT QUANTI and iMC SALT prototypes showed good results in validation tests. The preliminary results of the health impact of the iMC SALT prototype will be presented at the conference. Lessons The implementation of innovative equipments to help consumers and catering industry to monitor or control the addition of salt during preparation of food or cooking are expected to be available soon and to be useful to consumers and catering industry to reduce salt intake. Key messages Innovative equipments may contribute to estimate salt in foods, and to reduce salt added during culinary. The implementation of an equipment to control culinary salt could be one valid approach to reduce salt consumption with impact on health.

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P1691Impact of dose and duration of dietary salt reduction on blood pressure levels: systematic review and meta-analysis of randomised trials

European Heart Journal ◽

10.1093/eurheartj/ehz748.0446 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Huang ◽

K Trieu ◽

S Yoshimura ◽

M Woodward ◽

N Campbell ◽

...

Keyword(s):

Blood Pressure ◽

Systolic Blood Pressure ◽

Diastolic Blood Pressure ◽

Sodium Excretion ◽

Salt Intake ◽

Meta Analysis ◽

Dietary Salt ◽

Baseline Blood Pressure ◽

Salt Reduction ◽

The Impact

Abstract Background Authoritative medical and public health agencies in most countries advise to reduce population dietary salt intake to under 5–6 g/day as a strategy for preventing high blood pressure and cardiovascular disease. However, there is still dispute about whether salt reduction should be adopted by all populations. In addition, the effect of duration of dietary salt reduction has not been sufficiently investigated. Purpose To understand the effect of dietary salt reduction on blood pressure and the impact of intervention duration. Methods A systematic review and meta-analysis was conducted. Randomized controlled trials that allocated participants to low and high salt intake, without confounding from unequal concomitant interventions, were included. We excluded studies done in individuals younger than 18 years, pregnant women, individuals with renal disease or heart failure, and studies with sodium excretion estimated from spot urine. Random effect meta-analysis was used to generate pooled estimates of the effect on 24-hour urinary sodium excretion, systolic and diastolic blood pressure. Multivariate meta-regression was used to quantify the dose response effect of dietary salt on blood pressure change and to understand the impact of the intervention duration. Results 125 studies were included with 162 data points extracted. Ninety-nine data points (61%) had interventions under 4 weeks. Overall, 24-hour urinary sodium excretion changed by −141 mmol (95% CI: −156; −126), systolic blood pressure changed by −4.4 mm Hg (95% CI: −5.2; −3.7) and diastolic blood pressure changed by −2.4 mm Hg (95% CI: −2.9; −1.9). Sodium reduction resulted in a significant decrease of systolic blood pressure in all subgroups except in participants with low baseline sodium intake (<109 mmol) (Figure 1). Each 100 mmol reduction of sodium was associated with 2.7 mm Hg (95% CI: 1.0; 4.4; p=0.002) reduction of systolic blood pressure and 1.2 mm Hg (95% CI: 0.0; 2.4; p=0.046) reduction of diastolic blood pressure after adjusting for intervention duration, age, sex, race, baseline blood pressure, baseline sodium intake and interaction between age and baseline blood pressure. For the same amount of salt reduction, a 10 mm Hg higher baseline systolic blood pressure would result in 2.5 mm Hg greater reduction of systolic blood pressure. There is not enough evidence to show the impact of intervention duration. Figure 1 Conclusions Our meta-analysis showed that sodium reduction could reduce blood pressure in all adult populations regardless of age, sex and race. The effect of salt reduction on systolic blood pressure increases with higher baseline blood pressure. Further studies, designed to investigate the impact of intervention duration, are needed to understand the significance of the duration. Acknowledgement/Funding None

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Salt reduction in bread: Is it enough? Preliminary results of a HIA in Portugal

European Journal of Public Health ◽

10.1093/eurpub/ckz187.027 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

J Santos ◽

P Braz ◽

A Costa ◽

L Costa ◽

M Santos ◽

...

Keyword(s):

Blood Pressure ◽

Statistical Difference ◽

Salt Intake ◽

Statistical Significance ◽

Systolic Pressure ◽

Health Impact ◽

World Health ◽

Salt Reduction ◽

Aggregated Data ◽

The Impact

Abstract Issue Health Impact Assessment (HIA) is a methodology that aims at assessing the impact of policies in health. A pilot HIA is in progress to kick off the implementation of this methodology in Portugal with the support of the World Health Organization (WHO). In this context, the impact of a nation-wide policy that intends to achieve a maximum of 1 g of salt/100 gr in bread is under assessment. Description of the issue In 2017, Portugal approved a protocol between the industry and other stakeholders to gradually decrease the amount of salt in bread, as this is the main source of salt intake. The purpose of this study was to assess the impact in blood pressure from current (1.4 gr) to 1 g (29% reduction) of salt in bread. Data from two different surveys regarding blood pressure and salt intake was gathered. We estimated the decrease in blood pressure with respect to current average values according to sex, age, education and region. Results It is expected that a reduction of 29% in salt intake through bread contributes to a general decrease in systolic pressure for normotensive people (from 120.4mmHg to 120.0mmHg, p = 0.85) and hypertensive people (from 151.0mmHg to 150.1mmHg, p = 0.68), although not statistically significant. Older hypertensive individuals (65 to 75 years) are the group with the largest benefit (152.8mmHg to 152.0mmHg) but no statistical difference was found. Disaggregation by sex, region and education also didn’t show any statistical difference. Lessons The impact in blood pressure from a 29% reduction in salt intake from bread seems very small. We found no statistical significance between the current and expected values in blood pressure either for total or group stratification. The absence of statistical effect might be due to sample size as our sources only allowed us to work with aggregated data. Key messages Quality and access to data is needed to assess impact of policies. to increase effects in blood pressure either salt reduction from bread must be larger or a wider range of products should be considered.

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Salt as a public health challenge in continental European convenience and ready meals

Public Health Nutrition ◽

10.1017/s1368980014000731 ◽

2014 ◽

Vol 17 (11) ◽

pp. 2459-2466 ◽

Cited By ~ 14

Author(s):

Sonja Kanzler ◽

Christina Hartmann ◽

Anita Gruber ◽

Guido Lammer ◽

Karl-Heinz Wagner

Keyword(s):

Public Health ◽

Salt Intake ◽

Salt Content ◽

Daily Intake ◽

Health Impact ◽

Salt Reduction ◽

High Salt Intake ◽

Increased Risk ◽

Comprehensive Survey ◽

The Uk

AbstractObjectiveTo assess the salt content of continental European convenience and ready meals.DesignA multistage study in which, after laboratory analysis of the products’ salt contents (n32), new salt-reduced meals were developed through food reformulation. Additionally, a comprehensive survey of convenience meals from the Austrian market (n572) was conducted to evaluate the salt contents of a wider product range.SettingSix continental European countries participated.SubjectsNo subjects enrolled.ResultsThe salt contents of continental European convenience and ready meals mostly exceeded 1·8 g/100 g, which is 30 % of the targeted daily intake level; some contained even more than the recommended daily intake of 6 g. The highest salt contents were found in pizzas and pasta dishes, the lowest ones in sweet meals. Large variations in salt levels were found not only between and within meal type categories, but also between similar meals from different producers. In addition, our approach to develop new salt-reduced meals showed that a stepwise reduction of the ready meals’ salt contents is possible without compromising the sensory quality.ConclusionsTo address the problem of hypertension and increased risk for CVD through high salt intake, a reduction of the salt levels in continental European convenience and ready meals is urgently needed, since they are providing a major part of the daily salt intake. Successful national-wide salt reduction strategies in the UK or Finland have already demonstrated the public health impact of this setting.

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Salt Intake in Nigeria: a nationwide population survey

European Heart Journal ◽

10.1093/ehjci/ehaa946.2866 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A.N Odili ◽

B.S Chori ◽

B Danladi ◽

P.C Nwakile ◽

J.O Ogedengbe ◽

...

Keyword(s):

Salt Intake ◽

Sodium Intake ◽

Population Analysis ◽

Cost Effective ◽

Rural Site ◽

Urban Site ◽

Funding Source ◽

Salt Reduction ◽

High Salt Intake ◽

The Impact

Abstract Background Population wide salt reduction programmes are cost effective strategies for control of cardiovascular diseases (CVDs). Obtaining a nationwide salt consumption data in a multi-cultural setting as Nigeria's is key for proper implementation and monitoring of such strategy. Methods We measured sodium in 24-hour urine of free-living adult Nigerians selected from an urban and a rural site each from the 6 geopolitical zones of Nigeria to evaluate patterns of salt intake and its associations with blood pressures (BP). Results Across the 12 sites, sodium intake ranged from 97.9 in the rural South-South to 210 mmol/day in the urban site of the same zone. Overall, the median (IQR) daily sodium intake was 143.5 (97.8) mmol; with higher (p=0.0028) levels among the urban 149.7 (113.8) compared to the rural 133.1 (105.2) dwellers. Overall, 20% of the subjects consumed less than the recommended 2g (86mmol) of sodium daily. After adjustment for age, sex and BMI; sodium intake and BP (systolic and diastolic) were positively associated in 8 out of the 12 sites; significantly so in 2 (p<0.05) for systolic. Within population analysis; which included 973 individuals, increasing sodium intake tended (not significantly) to increase SBP but decrease DBP. However, among subjects whose sodium intake was in excess of 257mmol/day, a 100 mmol/day increase in sodium intake was significantly (p=0.04) associated with a 3.3 mmHg increase in SBP. Conclusion Salt intake among Nigerians is higher than the recommended. The impact of sodium intake on BP appears to be evident only among individuals with high salt intake. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Wellcome Trust

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Developing a policy to reduce the salt content of food consumed outside the home in Malaysia: protocol of a qualitative study

BMJ Open ◽

10.1136/bmjopen-2020-044628 ◽

2021 ◽

Vol 11 (7) ◽

pp. e044628

Author(s):

Mhairi Karen Brown ◽

Suzana Shahar ◽

Yee Xing You ◽

Viola Michael ◽

Hazreen Abdul Majid ◽

...

Keyword(s):

Medical Research ◽

Research Ethics ◽

Salt Intake ◽

Salt Content ◽

Ethics Committee ◽

Salt Reduction ◽

Reduction Strategy ◽

Research Ethics Committee ◽

School Canteen ◽

Medical Research Ethics

IntroductionCurrent salt intake in Malaysia is high. The existing national salt reduction policy has faced slow progress and does not yet include measures to address the out of home sector. Dishes consumed in the out of home sector are a known leading contributor to daily salt intake. This study aims to develop a salt reduction strategy, tailored to the out of home sector in Malaysia.Methods and analysisThis study is a qualitative analysis of stakeholder views towards salt reduction. Participants will be recruited from five zones of Malaysia (Western, Northern, Eastern and Southern regions and East Malaysia), including policy-makers, non-governmental organisations, food industries, school canteen operators, street food vendors and consumers, to participate in focus group discussions or in-depth interviews. Interviews will be transcribed and analysed using thematic analysis. Barriers will be identified and used to develop a tailored salt reduction strategy.Ethics and disseminationEthical approval has been obtained from the Universiti Kebangsaan Malaysia Medical Research Ethics Committee (UKM PPI/1118/JEP-2020–524), the Malaysian National Medical Research Ethics Committee (NMRR-20-1387-55481 (IIR)) and Queen Mary University of London Research Ethics Committee (QMERC2020/37) . Results will be presented orally and in report form and made available to the relevant ministries for example, Ministry of Health, Ministry of Education and Ministry of Trade to encourage adoption of strategy as policy. The findings of this study will be disseminated through conference presentations, peer-reviewed publications and webinars.

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Evaluation of salt content in school meals

Revista de Nutrição ◽

10.1590/1415-52732015000200005 ◽

2015 ◽

Vol 28 (2) ◽

pp. 165-174 ◽

Cited By ~ 2

Author(s):

Cláudia Alexandra Colaço Lourenço Viegas ◽

Jorge Torgal ◽

Pedro Graça ◽

Maria do Rosário Oliveira Martins

Keyword(s):

High School Students ◽

Salt Intake ◽

Eating Habits ◽

Salt Content ◽

Food Samples ◽

Mean Value ◽

School Meals ◽

School Students ◽

Salt Reduction ◽

Reduction Strategies

OBJECTIVE: High blood pressure is a major rick factor for cardiovascular disease, and it is closely associated with salt intake. Schools are considered ideal environments to promote health and proper eating habits. Therefore the objective of this study was to evaluate the amount of salt in meals served in school canteens and consumers' perceptions about salt. METHODS: Meals, including all the components (bread, soup, and main dish) were retrieved from school canteens. Salt was quantified by a portable salt meter. For food perception we constructed a questionnaire that was administered to high school students. RESULTS: A total of 798 food samples were analysed. Bread had the highest salt content with a mean of 1.35 g/100 g (SD=0.12). Salt in soups ranged from 0.72 g/100 g to 0.80 g/100 g (p=0.05) and, in main courses, from 0.71 g/100 to 0.97 g/100g (p=0.05). The salt content of school meals is high with a mean value of 2.83 to 3.82 g of salt per meal. Moreover, a high percentage of students consider meals neither salty nor bland, which shows they are used to the intensity/amount of salt consumed. CONCLUSION: The salt content of school meals is high, ranging from 2 to 5 times more than the Recommended Dietary Allowances for children, clearly exceeding the needs for this population, which may pose a health risk. Healthy choices are only possible in environments where such choices are possible. Therefore, salt reduction strategies aimed at the food industry and catering services should be implemented, with children and young people targeted as a major priority.

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Assessment of Sodium Knowledge and Urinary Sodium Excretion among Regions of the United Arab Emirates: A Cross-Sectional Study

Nutrients ◽

10.3390/nu12092747 ◽

2020 ◽

Vol 12 (9) ◽

pp. 2747

Author(s):

Amjad H. Jarrar ◽

Lily Stojanovska ◽

Vasso Apostolopoulos ◽

Leila Cheikh Ismail ◽

Jack Feehan ◽

...

Keyword(s):

United Arab Emirates ◽

Sodium Excretion ◽

Salt Intake ◽

Urinary Sodium Excretion ◽

World Health ◽

High Potassium ◽

Cross Sectional ◽

Salt Reduction ◽

High Salt Intake ◽

The Impact

Non-communicable diseases (NCDs) such as cardiovascular disease, cancer and diabetes, are increasing worldwide and cause 65% to 78% of deaths in the Gulf Cooperation Council (GCC). A random sample of 477 healthy adults were recruited in the United Arab Emirates (UAE) in the period March–June 2015. Demographic, lifestyle, medical, anthropometric and sodium excretion data were collected. A questionnaire was used to measure knowledge, attitude and practice regarding salt. Mean sodium and potassium excretion were 2713.4 ± 713 mg/day and 1803 ± 618 mg/day, respectively, significantly higher than the World Health Organization (WHO) recommendations for sodium (2300 mg/day) and lower for potassium (3150 mg/day). Two-thirds (67.4%) exceeded sodium guidelines, with males 2.6 times more likely to consume excessively. The majority of the participants add salt during cooking (82.5%) and whilst eating (66%), and 75% identified processed food as high source of salt. Most (69.1%) were aware that excessive salt could cause disease. Most of the UAE population consumes excess sodium and insufficient potassium, likely increasing the risk of NCDs. Despite most participants being aware that high salt intake is associated with adverse health outcomes, this did not translate into salt reduction action. Low-sodium, high-potassium dietary interventions such as the Mediterranean diet are vital in reducing the impact of NCDs in the UAE.

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A Mobile Health Salt Reduction Intervention for People With Hypertension: Results of a Feasibility Randomized Controlled Trial (Preprint)

10.2196/preprints.26233 ◽

2020 ◽

Author(s):

Sarah Payne Riches ◽

Carmen Piernas ◽

Paul Aveyard ◽

James P Sheppard ◽

Mike Rayner ◽

...

Keyword(s):

Blood Pressure ◽

Primary Care ◽

Randomized Controlled Trial ◽

Salt Intake ◽

Controlled Trial ◽

Salt Content ◽

Salt Reduction ◽

Randomized Controlled ◽

Secondary Outcomes

BACKGROUND A high-salt diet is a risk factor for hypertension and cardiovascular disease; therefore, reducing dietary salt intake is a key part of prevention strategies. There are few effective salt reduction interventions suitable for delivery in the primary care setting, where the majority of the management and diagnosis of hypertension occurs. OBJECTIVE The aim of this study is to assess the feasibility of a complex behavioral intervention to lower salt intake in people with elevated blood pressure and test the trial procedures for a randomized controlled trial to investigate the intervention’s effectiveness. METHODS This feasibility study was an unblinded, randomized controlled trial of a mobile health intervention for salt reduction versus an advice leaflet (control). The intervention was developed using the Behavior Change Wheel and comprised individualized, brief advice from a health care professional with the use of the SaltSwap app. Participants with an elevated blood pressure recorded in the clinic were recruited through primary care practices in the United Kingdom. Primary outcomes assessed the feasibility of progression to a larger trial, including follow-up attendance, fidelity of intervention delivery, and app use. Secondary outcomes were objectively assessed using changes in salt intake (measured via 24-hour urine collection), salt content of purchased foods, and blood pressure. Qualitative outcomes were assessed using the think-aloud method, and the process outcomes were evaluated. RESULTS A total of 47 participants were randomized. All progression criteria were met: follow-up attendance (45/47, 96%), intervention fidelity (25/31, 81%), and app use (27/31, 87%). There was no evidence that the intervention significantly reduced the salt content of purchased foods, salt intake, or blood pressure; however, this feasibility study was not powered to detect changes in secondary outcomes. Process and qualitative outcomes demonstrated that the trial design was feasible and the intervention was acceptable to both individuals and practitioners and positively influenced salt intake behaviors. CONCLUSIONS The intervention was acceptable and feasible to deliver within primary care; the trial procedures were practicable, and there was sufficient signal of potential efficacy to change salt intake. With some improvements to the intervention app, a larger trial to assess intervention effectiveness for reducing salt intake and blood pressure is warranted. CLINICALTRIAL International Standard Randomized Controlled Trial Number (ISRCTN): 20910962; https://www.isrctn.com/ISRCTN20910962

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Estimated public health gains from smokers in Germany switching to risk-reduced alternatives: Results from population health impact modelling by socioeconomic group

10.21203/rs.3.rs-135254/v1 ◽

2020 ◽

Author(s):

Romana Rytsar ◽

Smilja Djurdjevic ◽

Alexander K Nussbaum ◽

Ashok Kaul ◽

Emanuel Bennewitz ◽

...

Keyword(s):

Transition Probabilities ◽

Health Impact ◽

Socioeconomic Group ◽

Socioeconomic Groups ◽

Health Gains ◽

Alternative Scenarios ◽

Group B ◽

The Individual ◽

The Impact ◽

Reduced Risk

Abstract Background Previously, we estimated the impact of introducing heat-not-burn products and e-cigarettes in Germany between 1995 and 2015 on mortality from the four main smoking-related diseases in men and women aged 30–79 years. Deaths would have reduced by 216,650 (from 852,357 for continued smoking) had everyone quit smoking in 1995 and by 39,818 − 179,470 had one or both of heat-not burn products and e-cigarettes been introduced and adopted to varying extents. Here, we report substantial mortality reductions separately in two socioeconomic groups (A = higher, B = lower) defined by income and education. Methods Modelling is essentially as before, with individuals of a given sex, age range and cigarette smoking distribution followed over time under a “Null Scenario” (reduced-risk products never introduced) and various “Alternative Scenarios” (reduced-risk products introduced), the individual product histories generated then allowing estimation of reductions in mortality for each Alternative Scenario compared to the Null Scenario. Here, however, individuals are subdivided into two socioeconomic groups with transition probabilities between product use groups varying by group as well as by sex, age and length of follow-up. The possibility of transitioning between socioeconomic groups is also allowed for. Results Where all cigarette smokers switch immediately, half to each new product, the drops in deaths were estimated as 60,081 in group A and 122,343 in group B, about 82% of the drops associated with immediate cessation (72,725 A, 147,684 B). Where the conversion was more gradual, the drops were about 35% of those from cessation (25,648 A, 52,652 B). Drops were about two times higher in B, because of their greater numbers, older age, and higher frequency of current smokers. Years of life saved were also higher (about 1.5 times) in B than A. Conclusions Methodological limitations would not have affected our conclusion that introducing these products in 1995 in Germany could have substantially reduced mortality in each group, with greater gains in B. While cessation is the best choice to reduce mortality, switching to reduced-risk products also provides substantial health gains. Encouraging lower socioeconomic group smokers who would otherwise continue smoking to fully switch to reduced-risk products could diminish smoking-related health inequalities.

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