A review of the world's salt reduction policies and strategies - preparing for the upcoming year 2025

Excessive consumption of dietary sodium is a significant contributor to non-communicable diseases, including hypertension and cardiovascular disease. There is now a global consensus that regulating salt intake is among the most cost-effective measures for enhancing public health. More than half of the countries worldwide have implemented multiple strategies to decrease salt consumption. Nevertheless, a report on sodium intake reduction published by the World Health Organization revealed that the world is off-track to meet its targeted reduction of 30% by 2025. The global situation regarding salt reduction remains concerning. This review will center on domestic and international salt reduction policies, as well as diverse strategies, given the detrimental effects of excessive dietary salt intake and the existing global salt intake scenario. Besides, we used visualization software to analyze the literature related to salt reduction research in the last five years to explore the research hotspots in this field. Our objective is to enhance public awareness regarding the imperative of reducing salt intake and promoting the active implementation of diverse salt reduction policies.

Assessing the contributions of an urban population health initiative to shift political priority towards cardiovascular health: three case studies from Brazil, Mongolia and Senegal

BACKGROUND

The urban population health initiative was designed as a multidisciplinary, multisector programme to address cardiovascular (CV) disease, specifically hypertension and its underlying causes in the cities of Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. This article aims to provide an overview of the history and dynamics of CV disease policy making in the three countries, to present the policy reform contributions of the initiative and its role in the policy agenda-setting framework/process in each country and to identify the enablers and challenges to the initiative for doing so.

METHODS

A qualitative case study was conducted for each setting from November 2020 to January 2021, comprised of a document review, semi-structured in-depth interviews and unstructured interviews with stakeholders involved in the initiative. The literature review included documents from the initiative and the peer-reviewed and grey literature with a total of 188 documents screened. Interviews were conducted with 21 stakeholders. Data collection and thematic analysis was guided by (i) the Kingdon multiple streams conceptual framework with the main themes being CV disease problems, policy, politics and the role of policy entrepreneurs; and (ii) the study question inquiring on the role of the urban population health initiative at the CV disease policy level and enabling and challenging factors to advancing CV disease policy. Data were thematically analysed using the Framework Method.

RESULTS

Each setting was characterized by a high hypertension and CV disease burden combined with an aware and proactive political environment. Policy outcomes attributed to the initiative were updating the guidelines and/or algorithms of care for hypertension and including revised physical and nutritional education in school curricula, in each city. Overall, the urban health initiative's effects in the policy arena, were most prominent in Mongolia and Senegal, where the team effectively acted as policy entrepreneur, promoting the solutions/policies in alignment with the most pressing local problems and in strong involvement with the political actors. The initiative was also involved in improving access to CV disease drugs at primary health levels. Its success was influenced by the local governance structures, the proximity of the initiative to the policy makers and the local needs. In Brazil, needs were expressed predominantly in the clinical practice.

CONCLUSIONS

This multi-country experience shows that, although the policy and political environment plays its role in shaping initiatives, often the local priority needs are the driving force behind wider change.

Emotional response to healthier foods: Influence of culture and health consciousness

Sugar, salt, and fat content in processed products are important concerns for consumers. Hence, alternative "healthy" versions of conventional foods such as chocolate, potato chips, and yogurt are offered. This work aimed to define the emotional response of consumers from different cultural backgrounds (Spain vs. Brazil) evoked by healthier versions of conventional products and the relationship between hedonic responses and health consciousness. A total of 186 Brazilian and 152 Spanish consumers participated in this online cross-cultural study. Participants answered a Health Consciousness Questionnaire and an emotional check-all-that-applies questionnaire using picture stimuli of conventional chocolate, potato chips, and yogurt and their healthier versions with less sugar, salt, and fat content, respectively. The Brazilians' emotional responses were more diverse for all stimuli compared to the Spaniards'. However, participants from both cultures rated an average of "slightly agree" on the health consciousness scale; a higher level of consumption, liking, and willingness to buy; and a higher frequency of positive emotional terms for the stimuli of conventional products compared to their healthier versions. A higher frequency of evocation of "active" is strongly associated with higher levels of health consciousness. Strategic actions by the food industry and government must consider cultural, emotional, and health-conscious factors to encourage the consumption of healthier foods. PRACTICAL APPLICATION: Food manufacturers can use the information obtained from this study to create healthier versions of their products that appeal to consumers' emotional responses and health consciousness levels. The findings can assist in designing strategic actions to promote healthier food consumption by emphasizing the benefits of healthier food choices and making them more appealing to consumers. The methodology employed in this study can also be applied to further studies aimed to assess emotional responses to food stimuli across different cultures.

Education-related health inequities in noncommunicable diseases: an analysis of the Brazilian National Health Survey, 2013 and 2019

This study assesses changes in the prevalence and distribution of noncommunicable diseases (NCDs) and related risk factors among Brazilian adults from the 2013 and 2019 Brazilian National Health Surveys (PNS). It is based on the hypothesis that deteriorating socioeconomic conditions over this period would lead to increased NCDs among the least advantaged populations. We estimated adjusted prevalence ratios by education category and three inequality measures - the slope index of inequality (SII), the relative index of inequality (RII), and population attributable fraction (PAF) - for obesity, hypertension, arthritis, asthma, cancer, depression, diabetes, heart disease, having any chronic condition, and multimorbidity by survey year. We also estimated the 27 Brazilian Federative Units RII and prevalence rates for diabetes and multimorbidity per year and plotted the RII against prevalence by year. Results showed that all NCDs increased over the period observed, ranging from an 8% increase in the adjusted prevalence of arthritis to a 24% increase in the adjusted prevalence of obesity. Measures of inequality showed that most conditions exhibited significant educational inequities in both 2013 and 2019. However, on average, education-based inequities did not significantly change between the two periods. Considering the deterioration of the socioeconomic conditions of most Brazilians, the erosion of social protections, and the continuing economic, political, and health crises occurring in the nation, we observed an urgent need for discussion about the best way to adopt equity-promoting health policies and programs and action to reduce socioeconomic and geographic inequalities in NCDs throughout the country.

Ricotta cream: classification based on moisture and fat content considering general standards for cheeses and cream cheeses

Ricotta cream though an emerging product sold in Brazil, by 2021 it has no fixed quality standards, a condition that can result in products with variable composition and properties. Additionally, there are no methods of sampling or analysis for its official control. In this context, this study investigated the physicochemical quality of five Brazilian ricotta cream brands to verify the extent of differences in the composition of this product, emphasizing the characterization and classification according to the Brazilian legislation and the Codex Alimentarius standards. Significant differences between brands concerning pH, titratable acidity, moisture, ash, fat, and fat in dry matter (FDM) were observed (P < 0.05), which were probably a result of their heterogeneous ingredient composition. According to Brazilian regulatory standards, all samples fit the "very high moisture" definition, and the brands A, B, D and E achieved the classification of "high-fat cheeses" since they contained at least 60.0% of FDM. Brand C was the only product that could be classified as a "medium fat cheese" due to having FDM values between 25.0% and 44.9%. All samples fit the Brazilian and Codex Alimentarius classification for "cream cheeses" based on their moisture, dry matter content, moisture on a fat-free basis and FDM. The results reinforce the need for regulatory standards regarding the physicochemical quality and composition of this cheese variety, to guarantee more transparency for the consumers and that they have access to more homogeneous products.

The politics of ultra-processed foods and beverages regulatory policy in upper-middle-income countries: Industry and civil society in Mexico and Brazil

ABSTRACTAddressing the politics of corporate political activity and policy interference in response to non-communicable diseases (NCDs) is a new area of scholarly research. The objective of this article is to explain how, in Mexico and Brazil, the ultra-processed foods and beverages industry succeeded in creating the political and social conditions conducive for their on-going regulatory policy influence and manipulation of scientific research. In addition to establishing partnerships within and outside of government, industry representatives have succeeded in hampering civic opposition by establishing allies within academia and society. Ministries of Health have simultaneously neglected to work closely with civil society, while legislative representatives have continued to benefit from industry campaign contributions. Findings from this article suggest that ultra-processed foods and beverages industries wield on-going regulatory policy influence in Mexico and Brazil, and that government is still not fully committed to working with civil society on these issues.

Changing diets and the transformation of the global food system

An aspirational global food system is one that delivers across a suite of the Sustainable Development Goals (SDGs), including universal access to healthy diets, which can also codeliver on climate and environment SDGs. The literature has downplayed the relative contribution of dietary change to sustainable food systems. In this perspective article, we argue that the potential for positive transformational change in diets should not be underestimated, for two sets of reasons. First, the dynamism of diets over long-term and, especially, recent history shows the potential for rapid and widespread change, including toward more diverse and healthier diets. Second, contemporary behavioral research demonstrates promising tactics to influence consumers' dietary choices. Since the entire food system creates the circumstances of those choices, the most effective strategies to shift diets will involve multiple approaches that deliberately aim not just to influence consumers themselves but also to incentivize all actors in the food systems, taking into account multiple agendas and values. The effectiveness of actions will depend on the political economy at local, national, and global levels. Overall, there are reasons to be hopeful about the potential for accelerated global dietary change, given both historic trends and the growing suite of tools and approaches available.

Compliance of declared vs. analysed values with EU tolerance limits for mandatory nutrients in prepacked foods

This study assessed compliance between declared and analysed values on prepacked foods, considering the tolerance limits for salt, fat and saturated fatty acids. Foods were distributed by food categories (e.g. snacks, ready-to-eat meals, potato and potato-products, bakery and pastry products) and a total of 209 products were analysed. Only half of the samples with a declared value ≥1.25 g/100 g were within tolerance limits for salt content. The lowest number of samples outside tolerance limits was observed for fat content; for saturated fatty acids, 27% of the samples were outside of tolerance limits. Only amongst "cereal products" were 100% of products compliant for fat and salt declarations. It is of utmost importance that manufacturers update continuously values declared for prepacked foods, because this information is crucial for consumers and food policy-makers as well as being a legal requirement.

Consumers' opinions on warning labels on food packages: A qualitative study in Brazil

This study aimed to assess consumers’ uses of and opinions on the current Brazilian food label and their reaction to the introduction of a front-of-package warning label. We conducted 12 focus groups among a diverse sample of adult consumers, to broadly assess: (1) uses of and perceptions about the current food label, and (2) opinions about implementing a front-of-package warning label to guide food purchases. Data was analyzed with a triangulation of researchers using an exploratory content analysis, which allowed codes to emerge from the data. The frequency of codes across focus groups was compared by gender and socioeconomic status to explore differences by these sociodemographic factors. Codes were divided into six main themes: (1) “Reasons for using food labels”; (2) “Barriers to using food labels”; (3) “Requirements for a new label”; (4) “Perceived influence on consumption behaviors”; (5) “Perceived influence on child behaviors”; and (6) “Perceptions of the food manufacturers using of warning labels”. Participants used food labels to check nutrient content and ingredient information but the format of these labels and the technicality of the content displayed often made the information inaccessible, particularly for those with low socioeconomic status. Most participants were supportive of the display of front-of-package warning labels on products and considered them useful to inform purchases. Women believed that they and their children would reduce the consumption of foods with front-of-package warning labels, while men reported more polarity in their intentions. For men and their children, front-of-package warning labels would result in either stopping food intake entirely or continued consumption without changes to the amount. The study results highlight the potential of front-of-package warning labels to support healthier behaviors in both consumers and their children.