CANADA

The 2004 Canadian Community Health Survey, a self-reported dietary recall survey, showed that among people 19 to 70 years of age, more than 85 percent of men and more than 60 percent of women consumed more than 2,300 mg sodium daily (the maximum intake level recommended in Canada) (Garriguet, 2007). Among children, 77 percent ages 1 to 3 years and 93 percent ages 4 to 8 years exceeded Tolerable Upper Intake Levels (ULs) of 1,500 and 1,900 mg/d, respectively (as established by the Institute of Medicine). Average sodium intake for both genders combined was 3,236 mg for ages 9 to 13 years; 3,534 mg for ages 14 to 18 years; 3,430 for ages 19 to 30 years; 3,207 mg for ages 31 to 50 years; and 2,954 mg for ages 51 to 70 years.

In 2006, the first Chair in Hypertension Prevention and Control was appointed. The chair, with support from health-related and science organizations, works to lobby the government to implement policies aimed at reducing the addition of salt to food (Campbell, 2007). A year later, the Minister of Health established a working group tasked with developing and implementing a strategy for reducing sodium intake among Canadians.

THE EUROPEAN UNION³

In 2008 a common framework was developed by the European Union (EU) to advance reduction in salt intake at the population level.⁴ A goal of this initiative is to achieve WHO’s strategies for a 16 percent reduction in salt intake during the next 4 years (against individual country baseline levels in 2008). The framework focuses on 12 categories of food that have been identified as priorities, of which each member state will choose at least 5 for its national plans. The first monitoring report is due in 2010.

FINLAND

Finland’s National Nutrition Council first initiated a salt reduction campaign in the late 1970s, when salt intake was estimated to be approximately 12 g/d (4,800 mg/d sodium), making it one of the first countries to attempt to systematically reduce the sodium intake of its population (He and MacGregor, 2009; Laatikainen et al., 2006). From 1979 to 1982, a community-based intervention called the North Karelia project was conducted to reduce mortality associated with cardiovascular disease by reducing population-wide sodium intake. Several stakeholders were involved with the project (health service organizations, schools, non-governmental organizations, media outlets, and the food industry) (European Commission, 2008). After 3 years, the project was expanded to include the entire country. Soon after, Finnish media, particularly the leading newspaper Hel-singin Sanomat, began releasing numerous reports on the harmful health effects of salt and helped to raise public (and government) awareness of salt and salt alternatives (Karppanen and Mervaala, 2006).

In 1993, salt-labeling legislation was implemented by the Ministry of Trade and Industry and the Ministry of Social Affairs and Health for food categories that contribute high amounts of sodium to the diet, such as manufactured food items and meals, requiring that such foods be labeled with the percentage of “salt (NaCl) by fresh weight of the product” (Pietinen et al., 2007). The legislation also requires a “high salt content” label on foods that contain high levels of sodium and allows foods low in sodium to carry a “low salt” label (see Table C-1). Other labels in use include the Pansalt logo (used on products with sodium-reduced, potassium- and magnesium-enriched mineral salts) and the “Better Choice” label that was put in use by the Finnish Heart Association in 2000 (He and MacGregor, 2009; Karppanen and Mervaala, 2006).

TABLE C-1

“High Salt Content” and “Low Salt” Label Requirements in Finland.

Monitoring of salt intake is conducted as part of FINRISK, a survey conducted every 5 years that includes an assessment of urinary sodium excretion. A study conducted between 1997 and 1999, using FINRISK surveys, estimated that 21 percent of sodium intake in households came from table salt (down from 30 percent in 1980) and about 70 percent came from processed foods (Reinivuo et al., 2006). By 2002, mean sodium intake was 3,900 mg/d for men and 2,700 mg/d for women. At that time, the most significant sources of sodium in Finnish diets (> 40 percent of intake) were meat dishes and bread. Fish, sausage dishes, and savory baked goods were also high contributors for men, as were fish, vegetable dishes, and savory baked goods for women (Reinivuo et al., 2006).

More recently a Finnish study (n = 2,007) estimated that if the entire Finnish adult population chose only products labeled as low salt (as determined by the requirements in Table C-1) as opposed to highly salted products, the mean salt intake could be reduced by 1.8 g (720 mg/d sodium) in men and 1.0 g (400 mg/d sodium) in women, whereas choosing only high-salt products could increase mean salt intake by 2.1 g (840 mg/d sodium) and 1.4 g (560 mg/d sodium), respectively (Pietinen et al., 2007).

During the time the initiative has been in place, sodium excretion levels, as well as blood pressure levels, have decreased. It has been reported that food companies either dropped products (to avoid selling products with a high-salt label) or began to reduce the sodium content of their foods by using alternatives such as mineral salts (European Commission, 2008; He and MacGregor, 2009).

FRANCE

In 2001 the Ministry of Health implemented the National Nutrition and Health Program (Programme National Nutrition Santé [PNNS]) with the goal of improving the health of the entire French population through nutrition interventions informed by input from several stakeholders in public and private sectors. One of the nine priority nutrition objectives of the program was to reduce the systolic blood pressure among adults (general population) by 10 mm Hg, which could partly be achieved by one of the 10 specific nutrition objectives to reduce the average consumption of sodium chloride to less than 8 g/d (3,200 mg/d sodium), which is equivalent to a 4 percent reduction in salt intake per year by the entire population over 5 years (Hercberg et al., 2008). The program implemented several strategies that were targeted to occur during a given year or over a period of time. The first set of activities included providing and promoting comprehensive nutrition communication for all consumers, which was done by disseminating information about the program and its objectives and publishing dietary reference guidelines and physical activity guidelines for the public, as well as food-based guides that offered advice on meeting PNNS recommendations (Hercberg et al., 2008). Mass media campaigns were launched to support the guides.

The next phase of action included ensuring a more healthful food supply and involving the food industry. One way of achieving this was to engage the food industry in formal commitments to improve the nutritional composition and quality of existing food products and to develop new products with higher nutritional standards, particularly in the areas of salt, sugar, and fat. The program also worked toward developing public health measures targeted at specific population groups; orienting actions toward health-care professionals and health services; mobilizing local authorities; establishing surveillance systems that monitor food consumption and the nutritional situation of the population; and developing epidemiological, behavioral, and clinical research in human nutrition (Hercberg et al., 2008). A national study to be released in 2010 will review the PNNS and report on the success of the program.

In addition, a working group convened by the French Food Standard Agency (AFSSA) released a report in 2002 that recommended a 20 percent reduction in the average salt intake over a 5-year period, which would bring the average intake from 10 g/d (4,000 mg/d sodium) to 7–8 g/d (2,800–3,200 mg/d sodium). To achieve this intake level, the working group developed initiatives for consumers, the food and catering industry, and medical professionals. Efforts were also initiated to encourage the food industry to adopt optional food labeling. Such labels, which are still in development, include listing sodium content in grams per 100 g or 100 mL and per serving (if necessary) and including the statement, “The salt (sodium) content of this product has been carefully studied; there is no need to add salt.”⁵ To date, no significant changes have been reported in the salt content of processed food or food labeling efforts.

IRELAND

The Food Safety Authority of Ireland (FSAI) began efforts in 2003 to reduce salt consumption by issuing a set of seven main objectives. The Salt Reduction Programme’s objectives included the goal of raising the food industry’s awareness about salt and health issues, working with manufacturers to gradually reduce the salt content of foods, and working on voluntary universal labeling of salt in packaged foods.⁶ The long-term goal of the program was to “reduce the average population intake of salt from 10 g/d to 6 g/d (from 4,000 to 2,400 mg/d sodium) by 2010 through partnership with the food industry and State bodies charged with communicating the salt and health message to consumers.”⁷

Further, in a 2005 report entitled “Salt and Health: Review of the Scientific Evidence and Recommendation for Public Policy in Ireland,” subcommittees of the FSAI concluded that there was a scientific link between salt consumption and high blood pressure and that reducing the average in-take to 6 g/d (2,400 mg/d sodium) could result in significantly fewer deaths from stroke and heart disease (He and MacGregor, 2009).

To track progress, the FSAI chronicles salt reduction commitments by food manufacturers, retailers, foodservice suppliers, and caterers on its website.⁸ At present, 63 companies and trade associations have registered with the FSAI’s Salt Reduction Programme. As reported by the FSAI, the program has resulted in large bread bakers’ reducing salt in all bread to levels below 1.14 g/100 g, representing a minimum 10 percent reduction in 5 years. Further, the agency reports that large and small meat product manufacturers have reduced salt in key products such as burgers and sausages and states that they are on course to meet FSAI targets for meat products by 2010. In addition, campaigns by the Irish Heart Foundation and the Food Safety Promotion Board are targeting the public to raise awareness about the health effects of a high salt intake.

THE UNITED KINGDOM

In 2003, the UK Scientific Advisory Committee on Nutrition (SACN) recommended that the public reduce salt intake to an average of 6 g/d (2,400 mg/d sodium) (SACN, 2003). The SACN used data from three national surveys to establish the 6 g target: (1) a 1990 24-hour urine collection reporting average daily salt intake of 9 g by adults; (2) a 1997 dietary intake survey of people 4–18 years of age that reported daily salt intake ranging from 4.7 to 8.3 g; and (3) a 1994–1995 dietary assessment survey of people 65-plus years of age with average daily salt intake of 6 g (SACN, 2003).

To help consumers reach the 6 g target, the UK government undertook a salt reduction program focused on three areas:

1. cooperation with the food industry to voluntarily reduce salt in foods;
2. a public campaign to raise awareness of why a high salt intake is detrimental to health and what the public can do to reduce intake; and
3. voluntary nutrition labeling placed on the front of food packages to provide information on the amount of salt and other nutrients in foods.

The following pages provide information on the three components of the UK salt reduction initiative as reported by the Food Standard Agency (FSA).⁹

Salt Reduction Program: Focus Areas

Involvement with the Food Industry

Recognizing that approximately three-quarters of dietary salt intake comes from processed food, FSA established voluntary targets for salt in a number of processed food categories.¹⁰ The targets are a means to track and report progress toward salt intake reductions and to provide guidance to industry. Starting with discussions that began in 2003, FSA developed a set of calculations to look at the potential impact of salt reductions in different food categories on population salt intake. The calculations were based on average sodium levels in foods within categories, weighted to account for varying consumption levels of different foods. The calculations were used to forecast how changes in the average salt content of various food categories can help the population reach the daily target of 6 g salt.¹¹ After soliciting and considering public comments, the final calculation spreadsheet was published in February 2005.¹²

Also in 2005, FSA Strategic Plan 2005–2010 was completed, which aimed to reduce the average population salt intake to 6 g/d (2,400 mg/d) by 2010 and to establish targets for salt content of key food categories by 2006. FSA consulted with the public and stakeholders to develop the final, voluntary salt targets for 2010, which were published in March 2006.¹² Eighty-five processed food categories including bread, bacon, breakfast cereals, and cheese were included among the target foods. FSA reported that it aimed to set challenging levels that would have a meaningful impact on consumer salt intake, while being mindful of food safety and technical issues and acknowledging that major processing changes would be necessary for certain foods to meet the targets.¹³

FSA reports that all sectors of the food industry have responded positively to the appeals to reduce salt in foods. To gauge progress, FSA uses a Processed Food Databank, a reference tool that provides information about the levels of sodium (and other nutrients) in processed foods based on data collected from product labels. The agency also purchases proprietary data listing sales figures and sodium levels in more than 130,000 products sold in the United Kingdom, using them to inform its review of salt targets.¹⁴ In addition, FSA maintains commitment documents from companies in the catering industry, such as restaurants, coffee shops, and workplace caterers. The commitment documents are updated annually and provide an overview of the company’s actions to support the Agency’s nutrition priorities, including sections on procurement, menu planning, kitchen practices, and customer information.¹⁵

FSA conducted a review in 2008 to gauge progress toward the 2010 salt targets and used the information it gathered to aid the process of setting revised targets for a limited range of food categories by 2010 and new targets for most foods by 2012. The review process included consultation by way of sector-specific meetings during which industry representatives reported on their progress, challenges, and potential future efforts to further reduce salt. FSA considered this industry input and other public comments as well as technical and safety issues, current salt intake, and public acceptance when proposing revised targets. Sixty responses were received from a range of stakeholders and were considered by the agency in revising the 2010 targets and establishing new targets for 2012. In May 2009, FSA published revised, voluntary salt reduction targets for 80 categories of food, for the industry to meet by 2012 (see Table C-2 at the end of this appendix). A small number of revisions were made for the 2010 targets (set forth in 2006) for foods that had already achieved the target or were close to doing so. The revised 2012 targets reflect the progress made thus far and are considered by FSA to serve as a continued challenge to industry to achieve salt levels that will help attain population salt intake of 6 g.¹⁶ In March 2010, the agency published documents listing commitments from a range of retailers, manufacturers, trade associations, and caterers highlighting progress made on salt reduction; these documents will be updated regularly to show progress.¹⁷

TABLE C-2

Food Standards Agency Salt Reduction Targets for 2010 and 2012.

FSA-Sponsored Awareness Campaign

Concurrent with the food industry plan, FSA launched a media campaign as part of the government salt reduction initiative.¹⁸ The first phase aimed to raise consumers’ awareness of the adverse health consequences of excessive salt consumption and ran from September to November 2004. It featured a character called “Sid the Slug” in poster, web, and print ads, with tag lines such as, “I’ve always known it: Too much salt is bad for your heart.” The second phase ran from October to November 2005; its key messages were to raise awareness of the goal to eat no more than 6 g salt per day and to encourage consumers to check the salt content on food labels. A series of short TV ads ran during the following summer to maintain awareness of the key messages.¹⁹ The third phase of the campaign commenced in March 2007, with the intent to inform consumers that most of the salt they eat is in everyday foods and to encourage them to chose lower-salt products. The fourth phase of consumer messaging began in October 2009 and highlighted the positive changes consumers could make to reduce salt intake, such as checking food labels to compare products and choosing the lower-salt option. The messages from the campaign have been disseminated through television and radio, print media, and on the web.¹⁷ In addition, the British Heart Foundation contributed to the awareness campaign by producing a booklet on the salt content of foods and the effect of a high salt intake on heart health (British Heart Foundation, 2007).

Voluntary Front-of-Package Nutrition Labeling

During the implementation of the salt reduction campaign, there have also been efforts to improve nutrition labeling for packaged foods. Salt content has been one area of focus for voluntary changes in labeling. Some supermarkets and manufacturers are voluntarily displaying front-of-package labeling of individual nutrients with a traffic light color system. The labeling scheme shows red, amber, or green colors to indicate that a product contains high, medium, or low levels of total fat, saturated fat, sugar, and salt.²⁰ Other supermarkets and manufacturers are using front-of-package labeling that provides the percentage of the Guideline Daily Amount (GDA) (an established recommended amount similar to the U.S. Daily Value) for selected nutrients, but without the traffic light color system (Malam et al., 2009).

Manufacturers and retailers may vary the label format, but certain core elements must be retained. The nutritional criteria determining the color coding for these voluntary labeling schemes were set by the government’s independent scientific advisory committees on nutrition. To qualify for a green light, a product must have ≤ 300 mg sodium per 100 g or 100 mL. A sodium content > 1,500 mg per 100 g or 100 mL receives a red light, and anything between 300 and 1,500 mg sodium per 100 g or 100 mL receives an amber light.²¹ This system was adopted based on consumer research showing that multiple traffic light colors were preferred over a single traffic light color, which would indicate only overall product healthfulness rather than amounts of a number of specific nutrients, such as sodium.²²

Recently, a study was conducted to determine how these labels are understood and used by consumers (Malam et al., 2009). The results of this study indicate that the use of different labeling formats by different retailers and manufacturers is confusing to consumers, suggesting that a uniform format may be preferable. It was also found that consumers interpret colors differently, and some did not realize that the colors had meaning. Overall, labels combining the words high, medium, and low in addition to traffic light colors and percentage of GDAs were found to be the easiest for consumers to understand, with approximately 70 percent of consumers comprehending the label meaning.

There is also some evidence to suggest that manufacturers have reformulated products to make their products qualify for a better traffic light profile (British Retail Consortium, 2009).

REFERENCES

1. British Heart Foundation. Salt: Facts for a healthy heart. London: British Heart Foundation; 2007.
2. British Retail Consortium. British retailing: A commitment to health. Martinez-Inchausti A, Gardiner A, editors. London: British Retail Consortium; 2009.
3. Campbell NRC. Canada Chair in hypertension prevention and control: A pilot project. Canadian Journal of Cardiology. 2007;23(7):557–560. [PMC free article: PMC2650759] [PubMed: 17534462]
4. EC (European Commission). Collated information on salt reduction in the EU. 2008. [accessed December 15, 2009]. http://ec​.europa.eu/health​/ph_determinants​/life_style/nutrition​/documents/compilation_salt_en.pdf.
5. Garriguet D. Sodium consumption at all ages. Health reports/statistics Canada. 2007;18(2):47–52. [PubMed: 17578015]
6. He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Journal of Human Hypertension. 2009;23(6):363–384. [PubMed: 19110538]
7. Hercberg S, Chat-Yung S, Chauliac M. The French national nutrition and health program: 2001–2006–2010. International Journal of Public Health. 2008;53(2):68–77. [PubMed: 18681335]
8. Karppanen H, Mervaala E. Sodium intake and hypertension. Progress in Cardiovascular Diseases. 2006;49(2):59–75. [PubMed: 17046432]
9. Laatikainen T, Pietinen P, Valsta L, Sundvall J, Reinivuo H, Tuomilehto J. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. European Journal of Clinical Nutrition. 2006;60(8):965–970. [PubMed: 16482074]
10. Malam S, Clegg S, Kirwin S, McGinigal S. British Market Research Bureau; 2009. [accessed March 10, 2010]. Comprehension and use of UK nutrition signpost labelling schemes (Prepared for the Food Standards Agency). http://www​.food.gov.uk​/multimedia/pdfs/pmpreport.pdf.
11. National Centre for Social Research. An assessment of dietary sodium levels among adults (aged 19–64 in the UK general population in 2008, based on analysis of dietary sodium in 24 hour urine samples. 2008. [accessed February 2, 2010]. http://www​.food.gov.uk​/multimedia/pdfs/08sodiumreport.pdf.
12. Pietinen P, Valsta LM, Hirvonen T, Sinkko H. Labelling the salt content in foods: A useful tool in reducing sodium intake in Finland. Public Health Nutrition. 2007;11(4):335–340. [PubMed: 17605838]
13. Reinivuo H, Valsta LM, Laatikainen T, Tuomilehto J, Pietinen P. Sodium in the Finnish diet: II Trends in dietary sodium intake and comparison between intake and 24-h excretion of sodium. European Journal of Clinical Nutrition. 2006;60(10):1160–1167. [PubMed: 16639417]
14. Scientific Advisory Committee on Nutrition. Salt and health. London, UK: Department of Health, Food Standards Agency (UK); 2003.
15. USDA (U.S. Department of Agriculture)/ARS (Agricultural Research Service). Nutrient intakes from food: Mean amounts consumed per individual, one day, NHANES 2005-2006. Washington, DC: Agricultural Research Service; 2008.
16. WHO (World Health Organization). Reducing risks, promoting healthy life World Health Report, 2002. Geneva: World Health Organization; 2002.
17. WHO. Diet, nutrition, and the prevention of chronic diseases WHO technical report series, No 916. Geneva: World Health Organization; 2003. [PubMed: 12768890]
18. WHO. Reducing salt intake in populations: Report of a WHO forum and technical meeting. Paris: World Health Organization; 2007.

Footnotes

1

Available online: http://www​.hc-sc.gc.ca​/fn-an/nutrition/sodium​/sodium_report_rapport​_20080722-eng.php (accessed March 24, 2010).

2

Available online: http://www​.hc-sc.gc.ca​/fn-an/food-guide-aliment/index-eng​.php (accessed October 15, 2009).

3

The European Union consists of 27 sovereign member states: Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, The Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the United Kingdom.

4

Available online: http://ec​.europa.eu/health​/ph_determinants​/life_style/nutrition​/nutrition_salt_en.htm (accessed October 14, 2009).

5

Available online: http://www​.worldactiononsalt​.com/action/france.doc (accessed October 26, 2009).

6

Available online: http://www​.fsai.ie/science_and_health​/salt_and_health​/objectives​_of_salt_programme.html (accessed October 13, 2009).

7

Available online: http://www​.fsai.ie/science_and_health​/salt_and_health.html (accessed October 13, 2009).

8

Available online: http://www​.fsai.ie/science_and_health​/salt​_commitments_and_updates.html (accessed October 13, 2009).

9

Available online: http://www​.food.gov.uk​/consultations/ukwideconsults​/2008/saltreductiontargets (accessed October 5, 2009).

10

Available online: http://www​.food.gov.uk​/multimedia/spreadsheets​/saltcommitmentsum.xls (accessed October 15, 2009).

11

Available online: http://www​.food.gov.uk​/consultations/ukwideconsults​/2003/saltmodellingconsult (accessed October 15, 2009).

12

Available online: http://www​.food.gov.uk​/healthiereating/salt/salttimeline (accessed March 24, 2010).

13

Available online: http://www​.food.gov.uk​/multimedia/pdfs/saltreductioninitiatives.pdf (accessed March 24, 2010).

14

Ibid.

15

Available online: http://www​.food.gov.uk​/healthiereating/healthycatering​/cateringbusiness​/commitments (accesed March 25, 2010).

16

Available online: http://www​.food.gov.uk​/healthiereating/salt/saltreduction (accessed Oc-tober 5, 2009).

17

Available online: http://www​.food.gov.uk​/news/newsarchive/2010​/mar/saltcommitments (accessed March 25, 2010).

18

Available online: http://www​.food.gov.uk​/healthiereating/salt/campaign (accessed March 22, 2010).

19

Available online: http://www​.food.gov.uk​/healthiereating/salt/salttimeline (accessed March 24, 2010).

20

Available online: http://www​.eatwell.gov​.uk/foodlabels/trafficlights/ (accessed October 15, 2009).

21

Available online: http://www​.food.gov.uk​/multimedia/pdfs/frontofpackguidance2​.pdf (accessed December 8, 2009).

22

Available online: http://www​.food.gov.uk​/foodlabelling/signposting​/devfop/siognpostlabelresearch/ (accessed December 8, 2009).

23

Available online: http://www​.food.gov.uk​/science/dietarysurveys/urinary (accessed October 13, 2009).

24

Available online: http://www​.food.gov.uk​/healthiereating/salt/saltreduction (accessed Oc-tober 5, 2009).