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Special Issue "Reducing Dietary Sodium and Improving Human Health"

A special issue of Nutrients (ISSN 2072-6643).

Deadline for manuscript submissions: closed (15 June 2017)

Special Issue Editor

Guest Editor
Dr. Jacqui Webster

The George Institute for Global Health, POB M201, Missenden Rd, Camperdown, NSW 2050, Australia
Website | E-Mail

Special Issue Information

Dear Colleagues,

This Special Issue of Nutrients, entitled “Reducing Dietary Sodium and Improving Human Health”, welcomes the submission of manuscripts either describing original research or reviewing scientific literature related to salt reduction. Manuscripts should focus on population interventions for reducing dietary sodium and we are particularly interested in innovative approaches to changing the food environment and/or consumer behaviour. Manuscripts that discuss theoretical models informing the design of interventions for reducing dietary sodium are also welcome, as are studies from low or lower middle income countries.

Potential topics may include, but are not limited to:

  • Development/evaluation of regional or national strategies to reduce population salt intake
  • Methodological issues related to measuring salt consumption patterns
  • Use of policy or legislative approaches to reduce salt consumption
  • Design and/or assessment of impact of behavioural change programs
  • Modelling of the impact of interventions on salt intake and health outcomes

Dr. Jacqui Webste
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Nutrients is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • salt
  • sodium
  • population interventions
  • behaviour change
  • food environment
  • evaluation
  • health outcomes
  • policy

Published Papers (19 papers)

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Research

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Open AccessArticle Characterization of Breakfast Cereals Available in the Mexican Market: Sodium and Sugar Content
Nutrients 2017, 9(8), 884; doi:10.3390/nu9080884
Received: 9 June 2017 / Revised: 27 July 2017 / Accepted: 3 August 2017 / Published: 16 August 2017
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Abstract
Preschool Mexican children consume 7% of their total energy intake from processed breakfast cereals. This study characterized the nutritional quality and labelling (claims and Guideline Daily Amount (GDA)) of the packaged breakfast cereals available in the Mexican market. Photographs of all breakfast cereals
[...] Read more.
Preschool Mexican children consume 7% of their total energy intake from processed breakfast cereals. This study characterized the nutritional quality and labelling (claims and Guideline Daily Amount (GDA)) of the packaged breakfast cereals available in the Mexican market. Photographs of all breakfast cereals available in the 9 main food retail chains in the country were taken. The nutrition quality of cereals was assessed using the United Kingdom Nutrient Profiling Model (UKNPM). Claims were classified using the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) taxonomy and the GDA was defined according to the Mexican regulation, NOM-051. Overall, a total of 371 different breakfast cereals were analysed. The nutritional profile showed that 68.7% were classified as “less healthy”. GDAs and claims were displayed more frequently on the “less healthy” cereals. Breakfast cereals within the “less healthy” category had significantly higher content of energy, sugar and sodium (p < 0.001). Most of the claims were displayed in the “less healthy” cereals (n = 313). This study has shown that there is a lack of consistency between the labelling on the front of the pack and the nutritional quality of breakfast cereals. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle The Healthy Eating Agenda in Australia. Is Salt a Priority for Manufacturers?
Nutrients 2017, 9(8), 881; doi:10.3390/nu9080881
Received: 15 June 2017 / Revised: 7 August 2017 / Accepted: 10 August 2017 / Published: 15 August 2017
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Abstract
Many nation states have endorsed and acted on the World Health Organization’s target of a 30% reduction in global salt consumption by 2025. In Australia, new government-led voluntary measures were initiated in 2009, consisting of public–private partnerships, front-of-pack labelling, and food reformulation targets
[...] Read more.
Many nation states have endorsed and acted on the World Health Organization’s target of a 30% reduction in global salt consumption by 2025. In Australia, new government-led voluntary measures were initiated in 2009, consisting of public–private partnerships, front-of-pack labelling, and food reformulation targets (which include reduced salt). How Australia’s private sector has responded to this healthy eating agenda has been investigated in a limited way, particularly with regards to manufacturers which produce processed foods considered significant sources of sodium. In this study we asked: have Australia’s largest food manufacturers made “…positive (nutrition) changes to their product portfolios” as disclosed in their public policies, priorities, and communications? And, is salt reduction a priority for processed food manufacturers? A systematic search and critical content-analysis of grey literature published by food manufacturers was conducted. The results suggest half of the sample publically describe some salt reduction activities but the scale and efficacy of these changes is unclear from the available literature. The Australian Government’s Healthy Food Partnership could capitalise on current documented activities in salt reduction, and implement a more comprehensive healthy eating agenda moving forward. In light of the increasing rates of hypertension, population salt consumption and diet-related disease, more could be done. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessArticle Changes in Consumer Attitudes toward Broad-Based and Environment-Specific Sodium Policies—SummerStyles 2012 and 2015
Nutrients 2017, 9(8), 836; doi:10.3390/nu9080836
Received: 12 June 2017 / Revised: 20 July 2017 / Accepted: 27 July 2017 / Published: 4 August 2017
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Abstract
We examined temporal changes in consumer attitudes toward broad-based actions and environment-specific policies to limit sodium in restaurants, manufactured foods, and school and workplace cafeterias from the 2012 and 2015 SummerStyle surveys. We used two online, national research panel surveys to conduct a
[...] Read more.
We examined temporal changes in consumer attitudes toward broad-based actions and environment-specific policies to limit sodium in restaurants, manufactured foods, and school and workplace cafeterias from the 2012 and 2015 SummerStyle surveys. We used two online, national research panel surveys to conduct a cross-sectional analysis of 7845 U.S. adults. Measures included self-reported agreement with broad-based actions and environment-specific policies to limit sodium in restaurants, manufactured foods, school cafeterias, workplace cafeterias, and quick-serve restaurants. Wald Chi-square tests were used to examine the difference between the two survey years and multivariate logistic regression was used to obtain odds ratios. Agreement with broad-based actions to limit sodium in restaurants (45.9% agreed in 2015) and manufactured foods (56.5% agreed in 2015) did not change between 2012 and 2015. From 2012 to 2015, there was a significant increase in respondents that supported environment-specific policies to lower sodium in school cafeterias (80.0% to 84.9%; p < 0.0001), workplace cafeterias (71.2% to 76.6%; p < 0.0001), and quick-serve restaurants (70.8% to 76.7%; p < 0.0001). Results suggest substantial agreement and support for actions to limit sodium in commercially-processed and prepared foods since 2012, with most consumers ready for actions to lower sodium in foods served in schools, workplaces, and quick-serve restaurants. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessArticle Urinary Sodium and Potassium Excretion and Dietary Sources of Sodium in Maputo, Mozambique
Nutrients 2017, 9(8), 830; doi:10.3390/nu9080830
Received: 10 June 2017 / Revised: 25 July 2017 / Accepted: 27 July 2017 / Published: 3 August 2017
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Abstract
This study aimed to evaluate the urinary excretion of sodium and potassium, and to estimate the main food sources of sodium in Maputo dwellers. A cross-sectional evaluation of a sample of 100 hospital workers was conducted between October 2012 and May 2013. Sodium
[...] Read more.
This study aimed to evaluate the urinary excretion of sodium and potassium, and to estimate the main food sources of sodium in Maputo dwellers. A cross-sectional evaluation of a sample of 100 hospital workers was conducted between October 2012 and May 2013. Sodium and potassium urinary excretion was assessed in a 24-h urine sample; creatinine excretion was used to exclude unlikely urine values. Food intake in the same period of urine collection was assessed using a 24-h dietary recall. The Food Processor Plus® was used to estimate sodium intake corresponding to naturally occurring sodium and sodium added to processed foods (non-discretionary sodium). Salt added during culinary preparations (discretionary sodium) was computed as the difference between urinary sodium excretion and non-discretionary sodium. The mean (standard deviation) urinary sodium excretion was 4220 (1830) mg/day, and 92% of the participants were above the World Health Organization (WHO) recommendations. Discretionary sodium contributed 60.1% of total dietary sodium intake, followed by sodium from processed foods (29.0%) and naturally occurring sodium (10.9%). The mean (standard deviation) urinary potassium excretion was 1909 (778) mg/day, and 96% of the participants were below the WHO potassium intake recommendation. The mean (standard deviation) sodium to potassium molar ratio was 4.2 (2.4). Interventions to decrease sodium and increase potassium intake are needed in Mozambique. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Stages of Behavioral Change for Reducing Sodium Intake in Korean Consumers: Comparison of Characteristics Based on Social Cognitive Theory
Nutrients 2017, 9(8), 808; doi:10.3390/nu9080808
Received: 18 June 2017 / Revised: 20 July 2017 / Accepted: 25 July 2017 / Published: 27 July 2017
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Abstract
High sodium intake increases the risk of cardiovascular disease. Given the importance of behavioral changes to reducing sodium intake, this study aims to investigate the stages of change and the differences in cognitive and behavioral characteristics by stage in Korean consumers. Adult participants
[...] Read more.
High sodium intake increases the risk of cardiovascular disease. Given the importance of behavioral changes to reducing sodium intake, this study aims to investigate the stages of change and the differences in cognitive and behavioral characteristics by stage in Korean consumers. Adult participants (N = 3892) completed a questionnaire on the stages of behavioral change, recognition of social efforts, outcome expectancy, barriers to practice, nutrition knowledge and dietary behaviors, and self-efficiency related to reduced sodium intake. The numbers of participants in each stage of behavioral change for reducing sodium intake was 29.5% in the maintenance stage, 19.5% in the action stage, and 51.0% in the preaction stage that included the precontemplation, contemplation, and preparation stages. Multiple logistic regression showed that the factors differentiating the three stages were recognizing a supportive social environment, perceived barriers to the practice of reducing sodium intake, and self-efficacy to be conscious of sodium content and to request less salt when eating out. Purchasing experience of sodium-reduced products for salty foods, knowledge of the recommended intake of salt and the difference between sodium and salt, and improving dietary habits of eating salted fish, processed food, and salty snacks were factors for being in the action stage versus the preaction stage. These findings suggest that tailored intervention according to the characteristics of each stage is helpful in reducing sodium intake. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessArticle Food Sources of Sodium Intake in an Adult Mexican Population: A Sub-Analysis of the SALMEX Study
Nutrients 2017, 9(8), 810; doi:10.3390/nu9080810
Received: 15 June 2017 / Revised: 19 July 2017 / Accepted: 25 July 2017 / Published: 27 July 2017
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Abstract
Excessive dietary sodium intake increases blood pressure and cardiovascular risk. In Western diets, the majority of dietary sodium comes from packaged and prepared foods (≈75%); however, in Mexico there is no available data on the main food sources of dietary sodium. The main
[...] Read more.
Excessive dietary sodium intake increases blood pressure and cardiovascular risk. In Western diets, the majority of dietary sodium comes from packaged and prepared foods (≈75%); however, in Mexico there is no available data on the main food sources of dietary sodium. The main objective of this study was to identify and characterize the major food sources of dietary sodium in a sample of the Mexican Salt and Mexico (SALMEX) cohort. Adult male and female participants of the SALMEX study who provided a complete and valid three-day food record during the baseline visit were included. Overall, 950 participants (mean age 38.6 ± 10.7 years) were analyzed to determine the total sodium contributed by the main food sources of sodium identified. Mean daily sodium intake estimated by three-day food records and 24-h urinary sodium excretion was 2647.2 ± 976.9 mg/day and 3497.2 ± 1393.0, in the overall population, respectively. Processed meat was the main contributor to daily sodium intake, representing 8% of total sodium intake per capita as measured by three-day food records. When savory bread (8%) and sweet bakery goods (8%) were considered together as bread products, these were the major contributor to daily sodium intake, accounting for the 16% of total sodium intake, followed by processed meat (8%), natural cheeses (5%), and tacos (5%). These results highlight the need for public health policies focused on reducing the sodium content of processed food in Mexico. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Salt Reductions in Some Foods in The Netherlands: Monitoring of Food Composition and Salt Intake
Nutrients 2017, 9(7), 791; doi:10.3390/nu9070791
Received: 15 June 2017 / Revised: 14 July 2017 / Accepted: 19 July 2017 / Published: 22 July 2017
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Abstract
Background and objectives. High salt intake increases blood pressure and thereby the risk of chronic diseases. Food reformulation (or food product improvement) may lower the dietary intake of salt. This study describes the changes in salt contents of foods in the Dutch market
[...] Read more.
Background and objectives. High salt intake increases blood pressure and thereby the risk of chronic diseases. Food reformulation (or food product improvement) may lower the dietary intake of salt. This study describes the changes in salt contents of foods in the Dutch market over a five-year period (2011–2016) and differences in estimated salt intake over a 10-year period (2006–2015). Methods. To assess the salt contents of foods; we obtained recent data from chemical analyses and from food labels. Salt content of these foods in 2016 was compared to salt contents in the 2011 version Dutch Food Composition Database (NEVO, version 2011), and statistically tested with General Linear Models. To estimate the daily dietary salt intake in 2006, 2010, and 2015, men and women aged 19 to 70 years were recruited through random population sampling in Doetinchem, a small town located in a rural area in the eastern part of the Netherlands. The characteristics of the study population were in 2006: n = 317, mean age 49 years, 43% men, in 2010: n = 342, mean age 46 years, 45% men, and in 2015: n = 289, mean age 46 years, 47% men. Sodium and potassium excretion was measured in a single 24-h urine sample. All estimates were converted to a common metric: salt intake in grams per day by multiplication of sodium with a factor of 2.54. Results. In 2016 compared to 2011, the salt content in certain types of bread was on average 19 percent lower and certain types of sauce, soup, canned vegetables and legumes, and crisps had a 12 to 26 percent lower salt content. Salt content in other types of foods had not changed significantly. Between 2006, 2010 and 2015 the estimated salt intake among adults in Doetinchem remained unchanged. In 2015, the median estimated salt intake was 9.7 g per day for men and 7.4 g per day for women. As in 2006 and 2010, the estimated salt intake in 2015 exceeded the recommended maximum intake of 6 g per day set by the Dutch Health Council. Conclusion. In the Netherlands, the salt content of bread, certain sauces, soups, potato crisps, and processed legumes and vegetables have been reduced over the period 2011–2016. However, median salt intake in 2006 and 2015 remained well above the recommended intake of 6 g. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Sodium Reduction in Processed Foods in Brazil: Analysis of Food Categories and Voluntary Targets from 2011 to 2017
Nutrients 2017, 9(7), 742; doi:10.3390/nu9070742
Received: 15 June 2017 / Revised: 7 July 2017 / Accepted: 10 July 2017 / Published: 12 July 2017
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Abstract
Non-communicable diseases, including cardiovascular diseases, are responsible for over 70% of deaths in Brazil. Currently, over 25% of Brazilian adults are diagnosed as hypertensive; overall, current dietary sodium intake in Brazil (4700 mg/person) is over twice the international recommendations, and 70–90% of adolescents
[...] Read more.
Non-communicable diseases, including cardiovascular diseases, are responsible for over 70% of deaths in Brazil. Currently, over 25% of Brazilian adults are diagnosed as hypertensive; overall, current dietary sodium intake in Brazil (4700 mg/person) is over twice the international recommendations, and 70–90% of adolescents and adults consume excessive sodium. National sodium reduction strategies consider the main dietary sources of sodium to be added salt to foods, foods consumed outside of the household, and sodium in processed foods. The national voluntary strategy for sodium reduction in priority food categories has been continuously monitored over a 6-year period (2011–2017) and there was a significant 8–34% reduction in the average sodium content of over half food categories. Different food categories have undergone differing reductions in sodium over time, aiding gradual biannual targets to allow industries to develop new technologies and consumers to adapt to foods with less salt. By 2017, most products of all food categories had met the regional targets proposed by the Pan American Health Organization, showing that voluntary sodium reduction strategies can potentially contribute to food reformulation. Nevertheless, regulatory approaches may still be necessary in the future in order to reach all food producers and to allow stronger enforcement to meet more stringent regional targets. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Taste, Salt Consumption, and Local Explanations around Hypertension in a Rural Population in Northern Peru
Nutrients 2017, 9(7), 698; doi:10.3390/nu9070698
Received: 7 April 2017 / Revised: 31 May 2017 / Accepted: 28 June 2017 / Published: 5 July 2017
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Abstract
Interventions to promote behaviors to reduce sodium intake require messages tailored to local understandings of the relationship between what we eat and our health. We studied local explanations about hypertension, the relationship between local diet, salt intake, and health status, and participants’ opinions
[...] Read more.
Interventions to promote behaviors to reduce sodium intake require messages tailored to local understandings of the relationship between what we eat and our health. We studied local explanations about hypertension, the relationship between local diet, salt intake, and health status, and participants’ opinions about changing food habits. This study provided inputs for a social marketing campaign in Peru promoting the use of a salt substitute containing less sodium than regular salt. Qualitative methods (focus groups and in-depth interviews) were utilized with local populations, people with hypertension, and health personnel in six rural villages. Participants were 18–65 years old, 41% men. Participants established a direct relationship between emotions and hypertension, regardless of age, gender, and hypertension status. Those without hypertension established a connection between eating too much/eating fried food and health status but not between salt consumption and hypertension. Participants rejected dietary changes. Economic barriers and high appreciation of local culinary traditions were the main reasons for this. It is the conclusion of this paper that introducing and promoting salt substitutes require creative strategies that need to acknowledge local explanatory disease models such as the strong association between emotional wellbeing and hypertension, give a positive spin to changing food habits, and resist the “common sense” strategy of information provision around the causal connection between salt consumption and hypertension. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessArticle Emerging Disparities in Dietary Sodium Intake from Snacking in the US Population
Nutrients 2017, 9(6), 610; doi:10.3390/nu9060610
Received: 17 May 2017 / Revised: 7 June 2017 / Accepted: 13 June 2017 / Published: 17 June 2017
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Abstract
Background: The US population consumes dietary sodium well in excess of recommended levels. It is unknown how the contribution of snack foods to sodium intake has changed over time, and whether disparities exist within specific subgroups of the US population. Objective: To examine
[...] Read more.
Background: The US population consumes dietary sodium well in excess of recommended levels. It is unknown how the contribution of snack foods to sodium intake has changed over time, and whether disparities exist within specific subgroups of the US population. Objective: To examine short and long term trends in the contribution of snack food sources to dietary sodium intake for US adults and children over a 37-year period from 1977 to 2014. Methods: We used data collected from eight nationally representative surveys of food intake in 50,052 US children aged 2–18 years, and 73,179 adults aged 19+ years between 1977 and 2014. Overall, patterns of snack food consumption, trends in sodium intake from snack food sources and trends in food and beverage sources of sodium from snack foods across race-ethnic, age, gender, body mass index, household education and income groups were examined. Results: In all socio-demographic subgroups there was a significant increase in both per capita sodium intake, and the proportion of sodium intake derived from snacks from 1977–1978 to 2011–2014 (p < 0.01). Those with the lowest household education, Non-Hispanic Black race-ethnicity, and the lowest income had the largest increase in sodium intake from snacks. While in 1977–1978 Non-Hispanic Blacks had a lower sodium intake from snacks compared to Non-Hispanic Whites (p < 0.01), in 2011–2014 they had a significantly higher intake. Conclusions: Important disparities are emerging in dietary sodium intake from snack sources in Non-Hispanic Blacks. Our findings have implications for future policy interventions targeting specific US population subgroups. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Know Your Noodles! Assessing Variations in Sodium Content of Instant Noodles across Countries
Nutrients 2017, 9(6), 612; doi:10.3390/nu9060612
Received: 11 April 2017 / Revised: 5 June 2017 / Accepted: 8 June 2017 / Published: 16 June 2017
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Abstract
Reducing salt intake is a cost-effective public health intervention to reduce the global burden of non-communicable disease (NCDs). Ultra-processed foods contribute ~80% of dietary salt in high income countries, and are becoming prominent in low-middle income countries. Instant noodle consumption is particularly high
[...] Read more.
Reducing salt intake is a cost-effective public health intervention to reduce the global burden of non-communicable disease (NCDs). Ultra-processed foods contribute ~80% of dietary salt in high income countries, and are becoming prominent in low-middle income countries. Instant noodle consumption is particularly high in the Asia Pacific region. The aim of this study was to compare the sodium content of instant noodles sold worldwide to identify potential for reformulation. Analysis was undertaken for 765 instant noodle products from 10 countries using packaged food composition databases of ultra-processed foods compiled by the Global Food Monitoring Group (GFMG) and national shop survey data. Sodium levels were high and variable, within and between countries. Instant noodles in China had the highest mean sodium content (1944 mg/100 g; range: 397–3678/100 g) compared to New Zealand (798 mg/100 g; range: 249–2380 mg/100 g). Average pack size ranged from 57 g (Costa Rica) to 98 g (China). The average packet contributed 35% to 95% of the World Health Organization recommended daily salt intake of <5 g. Forty percent of products met the Pacific Island (PICs) regional sodium targets, 37% met the South Africa 2016 targets, and 72% met the UK 2017 targets. This study emphasises a need for stronger regulation and closer monitoring to drive rigorous reformulation of salt in ultra-processed foods. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Changes in the Sodium Content of Australian Processed Foods between 1980 and 2013 Using Analytical Data
Nutrients 2017, 9(5), 501; doi:10.3390/nu9050501
Received: 14 March 2017 / Revised: 10 May 2017 / Accepted: 12 May 2017 / Published: 15 May 2017
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Abstract
The objective of this study was to obtain analytical data on the sodium content of a range of processed foods and compare the levels obtained with their label claims and with published data of the same or equivalent processed foods in the 1980s
[...] Read more.
The objective of this study was to obtain analytical data on the sodium content of a range of processed foods and compare the levels obtained with their label claims and with published data of the same or equivalent processed foods in the 1980s and 1990s to investigate the extent of any change in sodium content in relation to reformulation targets. The sodium contents of 130 Australian processed foods were obtained by inductively coupled plasma optical emission spectrometry (ICP-OES) analysis and compared with previously published data. The sodium content between 1980 and 2013 across all products and by each product category were compared. There was a significant overall sodium reduction of 23%, 181 mg/100 g (p <0.001, 95% CI (Confidence Interval), 90 to 272 mg/100 g), in Australian processed foods since 1980, with a 12% (83 mg/100 g) reduction over the last 18 years. The sodium content of convenience foods (p < 0.001, 95% CI, 94 to 291 mg/100 g) and snack foods (p = 0.017, 95% CI, 44 to 398 mg/100 g) had declined significantly since 1980. Meanwhile, the sodium contents of processed meats (p = 0.655, 95% CI, −121 to 190) and bread and other bakery products (p = 0.115, 95% CI, −22 to 192) had decreased, though not significantly. Conversely, the sodium content of cheese (p = 0.781, 95% CI, −484 to 369 mg/100 g) had increased but also not significantly. Of the 130 products analysed, 62% met Australian reformulation targets. Sodium contents of the processed foods and the overall changes in comparison with previous data indicate a decrease over the 33 years period and suggest that the Australian recommended reformulation targets have been effective. Further sodium reduction of processed foods is still required and continuous monitoring of the reduction of sodium levels in processed foods is needed. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Sodium and Potassium Intake in Healthy Adults in Thessaloniki Greater Metropolitan Area—The Salt Intake in Northern Greece (SING) Study
Nutrients 2017, 9(4), 417; doi:10.3390/nu9040417
Received: 13 March 2017 / Revised: 6 April 2017 / Accepted: 20 April 2017 / Published: 22 April 2017
Cited by 1 | PDF Full-text (650 KB) | HTML Full-text | XML Full-text
Abstract
A reduction in population sodium (as salt) consumption is a global health priority, as well as one of the most cost-effective strategies to reduce the burden of cardiovascular disease. High potassium intake is also recommended to reduce cardiovascular disease. To establish effective policies
[...] Read more.
A reduction in population sodium (as salt) consumption is a global health priority, as well as one of the most cost-effective strategies to reduce the burden of cardiovascular disease. High potassium intake is also recommended to reduce cardiovascular disease. To establish effective policies for setting targets and monitoring effectiveness within each country, the current level of consumption should be known. Greece lacks data on actual sodium and potassium intake. The aim of the present study was therefore to assess dietary salt (using sodium as biomarker) and potassium intakes in a sample of healthy adults in northern Greece, and to determine whether adherence to a Mediterranean diet is related to different sodium intakes or sodium-to-potassium ratio. A cross-sectional survey was carried out in the Thessaloniki greater metropolitan area (northern Greece) (n = 252, aged 18–75 years, 45.2% males). Participants’ dietary sodium and potassium intakes were determined by 24-hour urinary sodium and potassium excretions. In addition, we estimated their adherence to Mediterranean diet by the use of an 11-item MedDietScore (range 0–55). The mean sodium excretion was 175 (SD 72) mmol/day, equivalent to 4220 (1745) mg of sodium or 10.7 (4.4) g of salt per day, and the potassium excretion was 65 (25) mmol/day, equivalent to 3303 (1247) mg per day. Men had higher sodium and potassium excretions compared to women. Only 5.6% of the sample had salt intake <5 g/day, which is the target intake recommended by the World Health Organization. Mean sodium-to-potassium excretion ratio was 2.82 (1.07). There was no significant difference in salt or potassium intake or their ratio across MedDietScore quartiles. No significant relationships were found between salt intake and adherence to a Mediterranean diet, suggesting that the perception of the health benefits of the Mediterranean diet does not hold when referring to salt consumption. These results suggest the need for a larger, nation-wide survey on salt intake in Greece and underline the importance of continuation of salt reduction initiatives in Greece. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle The Sodium Content of Processed Foods in South Africa during the Introduction of Mandatory Sodium Limits
Nutrients 2017, 9(4), 404; doi:10.3390/nu9040404
Received: 9 March 2017 / Revised: 7 April 2017 / Accepted: 17 April 2017 / Published: 20 April 2017
Cited by 1 | PDF Full-text (491 KB) | HTML Full-text | XML Full-text
Abstract
Background: In June 2016, the Republic of South Africa introduced legislation for mandatory limits for the upper sodium content permitted in a wide range of processed foods. We assessed the sodium levels of packaged foods in South Africa during the one-year period leading
[...] Read more.
Background: In June 2016, the Republic of South Africa introduced legislation for mandatory limits for the upper sodium content permitted in a wide range of processed foods. We assessed the sodium levels of packaged foods in South Africa during the one-year period leading up to the mandatory implementation date of the legislation. Methods: Data on the nutritional composition of packaged foods was obtained from nutrition information panels on food labels through both in-store surveys and crowdsourcing by users of the HealthyFood Switch mobile phone app between June 2015 and August 2016. Summary sodium levels were calculated for 15 food categories, including the 13 categories covered by the sodium legislation. The percentage of foods that met the government’s 2016 sodium limits was also calculated. Results: 11,065 processed food items were included in the analyses; 1851 of these were subject to the sodium legislation. Overall, 67% of targeted foods had a sodium level at or below the legislated limit. Categories with the lowest percentage of foods that met legislated limits were bread (27%), potato crisps (41%), salt and vinegar flavoured snacks (42%), and raw processed sausages (45%). About half (49%) of targeted foods not meeting the legislated limits were less than 25% above the maximum sodium level. Conclusion: Sodium levels in two-thirds of foods covered by the South African sodium legislation were at or below the permitted upper levels at the mandatory implementation date of the legislation and many more were close to the limit. The South African food industry has an excellent opportunity to rapidly meet the legislated requirements. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessArticle Effect of 25% Sodium Reduction on Sales of a Top‐Selling Bread in Remote Indigenous Australian  Community Stores: A Controlled Intervention Trial
Nutrients 2017, 9(3), 214; doi:10.3390/nu9030214
Received: 19 December 2016 / Accepted: 21 February 2017 / Published: 28 February 2017
PDF Full-text (227 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Reducing sodium in the food supply is key to achieving population salt targets, but maintaining sales is important to ensuring commercial viability and maximising clinical impact. We investigated whether 25% sodium reduction in a top‐selling bread affected sales in 26 remote Indigenous community
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Reducing sodium in the food supply is key to achieving population salt targets, but maintaining sales is important to ensuring commercial viability and maximising clinical impact. We investigated whether 25% sodium reduction in a top‐selling bread affected sales in 26 remote Indigenous community stores. After a 23‐week baseline period, 11 control stores received the regular‐salt bread (400 mg Na/100 g) and 15 intervention stores received the reduced‐salt version (300 mg Na/100 g) for 12‐weeks. Sales data were collected to examine difference between groups in change from baseline to follow‐up (effect size) in sales (primary outcome) or sodium density, analysed using a mixed model. There was no significant effect on market share (−0.31%; 95% CI −0.68, 0.07; p = 0.11) or weekly dollars ($58; −149, 266; p = 0.58). Sodium density of all purchases was not significantly reduced (−8 mg Na/MJ; −18, 2; p = 0.14), but 25% reduction across all bread could significantly reduce sodium (−12; −23, −1; p = 0.03). We found 25% salt reduction in a top‐selling bread did not affect sales in remote Indigenous community stores. If achieved across all breads, estimated salt intake in remote Indigenous Australian communities would be reduced by approximately 15% of the magnitude needed to achieve population salt targets, which could lead to significant health gains at the population‐level. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessArticle The Association of Knowledge and Behaviours Related to Salt with 24-h Urinary Salt Excretion in a Population from North and South India
Nutrients 2017, 9(2), 144; doi:10.3390/nu9020144
Received: 19 December 2016 / Revised: 24 January 2017 / Accepted: 3 February 2017 / Published: 16 February 2017
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Abstract
Consumer knowledge is understood to play a role in managing risk factors associated with cardiovascular disease and may be influenced by level of education. The association between population knowledge, behaviours and actual salt consumption was explored overall, and for more-educated compared to less-educated
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Consumer knowledge is understood to play a role in managing risk factors associated with cardiovascular disease and may be influenced by level of education. The association between population knowledge, behaviours and actual salt consumption was explored overall, and for more-educated compared to less-educated individuals. A cross-sectional survey was done in an age-and sex-stratified random sample of 1395 participants from urban and rural areas of North and South India. A single 24-h urine sample, participants’ physical measurements and questionnaire data were collected. The mean age of participants was 40 years, 47% were women and mean 24-h urinary salt excretion was 9.27 (8.87–9.69) g/day. Many participants reported favourable knowledge and behaviours to minimise risks related to salt. Several of these behaviours were associated with reduced salt intake—less use of salt while cooking, avoidance of snacks, namkeens, and avoidance of pickles (all p < 0.003). Mean salt intake was comparable in more-educated (9.21, 8.55–9.87 g/day) versus less-educated (9.34, 8.57–10.12 g/day) individuals (p = 0.82). There was no substantively different pattern of knowledge and behaviours between more-versus less-educated groups and no clear evidence that level of education influenced salt intake. Several consumer behaviours related to use of salt during food preparation and consumption of salty products were related to actual salt consumption and therefore appear to offer an opportunity for intervention. These would be a reasonable focus for a government-led education campaign targeting salt. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)

Review

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Open AccessReview Applying a Consumer Behavior Lens to Salt Reduction Initiatives
Nutrients 2017, 9(8), 901; doi:10.3390/nu9080901 (registering DOI)
Received: 15 June 2017 / Revised: 10 August 2017 / Accepted: 16 August 2017 / Published: 18 August 2017
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Abstract
Reformulation of food products to reduce salt content has been a central strategy for achieving population level salt reduction. In this paper, we reflect on current reformulation strategies and consider how consumer behavior determines the ultimate success of these strategies. We consider the
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Reformulation of food products to reduce salt content has been a central strategy for achieving population level salt reduction. In this paper, we reflect on current reformulation strategies and consider how consumer behavior determines the ultimate success of these strategies. We consider the merits of adopting a ‘health by stealth’, silent approach to reformulation compared to implementing a communications strategy which draws on labeling initiatives in tandem with reformulation efforts. We end this paper by calling for a multi-actor approach which utilizes co-design, participatory tools to facilitate the involvement of all stakeholders, including, and especially, consumers, in making decisions around how best to achieve population-level salt reduction. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
Open AccessReview Time to Consider Use of the Sodium-to-Potassium Ratio for Practical Sodium Reduction and Potassium Increase
Nutrients 2017, 9(7), 700; doi:10.3390/nu9070700
Received: 12 May 2017 / Revised: 27 June 2017 / Accepted: 2 July 2017 / Published: 5 July 2017
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Abstract
Pathogenetic studies have demonstrated that the interdependency of sodium and potassium affects blood pressure. Emerging evidences on the sodium-to-potassium ratio show benefits for a reduction in sodium and an increase in potassium compared to sodium and potassium separately. As presently there is no
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Pathogenetic studies have demonstrated that the interdependency of sodium and potassium affects blood pressure. Emerging evidences on the sodium-to-potassium ratio show benefits for a reduction in sodium and an increase in potassium compared to sodium and potassium separately. As presently there is no known review, this article examined the practical use of the sodium-to-potassium ratio in daily practice. Epidemiological studies suggest that the urinary sodium-to-potassium ratio may be a superior metric as compared to separate sodium and potassium values for determining the relation to blood pressure and cardiovascular disease risks. Higher correlations and better agreements are seen for the casual urine sodium-to-potassium ratio than for casual urine sodium or potassium alone when compared with the 24-h urine values. Repeated measurements of the casual urine provide reliable estimates of the 7-day 24-h urine value with less bias for the sodium-to-potassium ratio as compared to the common formulas used for estimating the single 24-h urine from the casual urine for sodium and potassium separately. Self-monitoring devices for the urinary sodium-to-potassium ratio measurement makes it possible to provide prompt onsite feedback. Although these devices have been evaluated with a view to support an individual approach for sodium reduction and potassium increase, there has yet to be an accepted recommended guideline for the sodium-to-potassium ratio. This review concludes with a look at the practical use of the sodium-to-potassium ratio for assistance in practical sodium reduction and potassium increase. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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Open AccessReview A Systematic Review of Fatalities Related to Acute Ingestion of Salt. A Need for Warning Labels?
Nutrients 2017, 9(7), 648; doi:10.3390/nu9070648
Received: 7 June 2017 / Revised: 16 June 2017 / Accepted: 20 June 2017 / Published: 23 June 2017
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Abstract
There are sporadic cases of fatalities from acutely eating salt. Yet, on social media, there are “challenges to” and examples of children and some adults acutely eating salt, and recently a charity advocated eating small amounts of salt to empathize with Syrian refugees.
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There are sporadic cases of fatalities from acutely eating salt. Yet, on social media, there are “challenges to” and examples of children and some adults acutely eating salt, and recently a charity advocated eating small amounts of salt to empathize with Syrian refugees. We performed a systematic review of fatalities from ingesting salt to assess if relatively moderate doses of salt could be fatal. In 27 reports, there were 35 fatalities documented (19 in adults and 16 in children). The lethal dose was estimated to be less than 10 g of sodium (<5 teaspoons of salt) in two children, and less than 25 g sodium in four adults (<4 tablespoons of salt). The frequency of fatal ingestion of salt is not able to be discerned from our review. If investigation of the causes of hypernatremia in hospital records indicates salt overdose is relatively common, consideration could be given to placing warning labels on salt containers and shakers. Such warning labels can have the added advantage of reducing dietary salt consumption. Full article
(This article belongs to the Special Issue Reducing Dietary Sodium and Improving Human Health)
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