An Evaluation of the Sodium Content and Compliance with the National Sodium Reduction Targets among Packaged Foods Sold in Costa Rica in 2015 and 2018

Changes in the Sodium Content in Branded Foods in the Slovenian Food Supply (2011-2020)

High sodium intake is the leading diet-related risk factor for mortality globally. Many countries have introduced policies to support the reformulation of foods and to reduce sodium intake, mainly on a voluntary basis, but there are limited data available about the long-term efficiency of such measures. Slovenia implemented salt reduction policies for the period of 2010-2020; these policies also included the voluntary reformulation of foods with the lowering of sodium content. This study's aim was to explore the nationally representative branded food datasets collected in the years 2011, 2015, 2017, and 2020 to investigate the changes in the sodium content in prepacked branded foods. The study was conducted with datasets collected from food labels using standard food monitoring studies and included all the major retailers. Differences in market shares were adjusted by sales weighting, which was conducted using the yearly sales data provided by the major retailers. The food categories with a major contribution to the overall sales of sodium in prepacked branded foods were processed meat and derivatives (19.0%), canned vegetables (7.1%), water (6.7%), bread (7.2%), and cheese (6.3%). Considering the available food products, a notable decreasing sodium content trend was observed in biscuits, breakfast cereals, pizza, and spreads. Year-to-year differences were much less expressed after the correction for market share differences, and neutral trends were most frequently highlighted. This indicates that sodium was less frequently reduced in market-leading products. The study results revealed that very limited progress in sodium food reformulation was achieved in the 10-year period, indicating the need for more efficient policy approaches. The study demonstrated the importance of the systematic monitoring of the food supply for the evaluation of food policies.

A Program Evaluation of a Dietary Sodium Reduction Research Consortium of Five Low- and Middle-Income Countries in Latin America

Excess dietary sodium is a global public health priority, particularly in low- and middle-income countries where rates of hypertension and cardiovascular disease are high. The International Development Research Centre funded a research consortium of five Latin American countries (LAC) to inform public health policy for dietary sodium reduction (2016-2020). The objective of this study was to determine the outcomes of this funding on short-term (e.g., research, capacity building) and intermediary outcomes (e.g., policies). A summative program evaluation was conducted, using a logic model and multiple data sources including document review, surveys and interviews. Researchers from Argentina, Costa Rica, Brazil, Peru and Paraguay produced a significant amount of scientific evidence to guide decision making on sodium policy related to its content in foods, consumer behaviors (social marketing), and the health and economic benefits of dietary reduction. A substantive number of knowledge translation products were produced. The funding enabled training opportunities for researchers who developed skills that can be scaled-up to other critical nutrients and health issues. It was unexpected that intermediary policy changes would occur, however several countries demonstrated early policy improvements derived from this research. A funded research consortium of LAC is a practical approach to invoke policy innovations.

Prevalence of Excess Sodium Intake and Their Corresponding Food Sources in Adults from the 2017–2018 Brazilian National Dietary Survey

Excessive sodium intake has been related to high blood pressure, a central risk factor for cardiovascular disease. In the present work, updated estimates of sodium intake, the main food sources, and the prevalence of excessive intakes in a nationwide multi-ethnic sample of Brazilian adults (2017–2018 Brazilian National Dietary Survey) were presented. Based on two 24-h recalls adjusted for the within-person variation, the overall median of sodium intake was 2432 mg. The prevalence of adults exceeding the recommended limits (tolerable upper limit, UL, and the chronic disease risk reduction cut-off point, CDRR) was 61% and 56%, respectively. The median sodium intake and proportion of individuals above the limits varied according to the subgroups evaluated. Males and adults (20–29 years) presented the highest excessive sodium intakes, and consequently, lowest adherence rates to UL and CDRR recommendations. The top food sources of sodium were white bread and toast (12.3%), beans (11.6%), white rice (10.6%), beef (7.7%), and poultry meat (5.5%). Given the health benefits of dietary sodium reduction, it would be advisable to enhance the current national initiatives of awareness and educational campaigns’ combined efforts to reduce sodium in processed foods to effectively decrease this micronutrient intake across the Brazilian population.

A Global Review of National Strategies to Reduce Sodium Concentrations in Packaged Foods

Strategies to reduce sodium concentrations in packaged foods are effective and cost-effective approaches to reducing the burden of disease attributable to high sodium intakes. This review aimed to comprehensively describe, and explore characteristics of, national strategies to reduce sodium concentrations in packaged foods, and assess progress toward achieving national goals. A secondary aim was to understand the number, type, and variation of food category sodium targets set by countries compared with WHO global sodium benchmarks. National sodium reduction reformulation strategies were identified from a search of peer-reviewed and gray literature up to December 2019 supplemented by verified information from key contacts and experts up to December 2020. Key characteristics of countries' strategies were extracted, synthesized, and descriptively analyzed, including details of reformulation strategies and evaluation data. Country targets were mapped to the WHO global sodium benchmarks, and the number and variation of country sodium targets by WHO food categories were determined. Sixty-two countries had reformulation strategies to reduce sodium in packaged foods, and 19 countries had evaluated their reformulation strategies. Forty-three countries had sodium targets, which varied in type of targets (maximum sodium concentration: n = 26; maximum concentration plus relative reduction/average/sales-weighted average: n = 8; relative reduction: n = 7; average: n = 2), number of food category targets (range: n = 1 to 150), and regulatory approach (voluntary: n = 28; mandatory: n = 9; both: n = 6). Eight of 34 countries mapped to the WHO benchmarks had targets for just 1 specified food category (bread products). One-third of all countries were implementing national strategies to reduce sodium concentrations in packaged foods including establishing targets and/or processes for industry engagement. This review determined that there is scope to improve most countries' strategies. There has been limited progress in implementing and evaluating strategies between 2014 and 2019, and regional and income-level disparities persist. The WHO global sodium benchmarks present an important opportunity to accelerate reformulation action globally.

Development of the Food Label Information Program: A Comprehensive Canadian Branded Food Composition Database

Objectives

Traditional methods for creating food composition databases struggle to cope with the large number of products and the rapid pace of turnover in the food supply. This paper introduces Food Label Information Program (FLIP), a big data approach to the evaluation of the Canadian food supply and presents the latest methods used in the development of this database.

Methods

The Food Label Information Program (FLIP) is a database of Canadian food and beverage package labels by brand name. The latest iteration of the FLIP, FLIP 2020, was developed using website “scraping” to collect food labeling information (e.g., nutritional composition, price, product images, ingredients, brand, etc.) on all foods and beverages available on seven major Canadian e-grocery retailer websites between May 2020 and February 2021.

Results

The University of Toronto's Food Label Information Program (FLIP) 2020 was developed in three phases: Phase 1, database development and enhancements; Phase 2, data capture and management of food products and nutrition information; Phase 3, data processing and food categorizing. A total of 74,445 products available on websites of seven retailers and 2 location-specific duplicate retailers were collected for FLIP 2020. Of 57,006 food and beverage products available on seven retailers, nutritional composition data were available for about 60% of the products and ingredients were available for about 45%. Data for energy, protein, carbohydrate, fat, sugar, sodium and saturated fat were present for 54–65% of the products, while fiber information was available for 37%. Food products were classified under multiple categorization systems, including Health Canada's Table of Reference Amounts, Health Canada's sodium categories for guiding benchmark sodium levels, sugar-focused categories and categories specific to various global nutrient profiling models.

Conclusions

FLIP is a powerful tool for evaluating and monitoring the Canadian food supply environment. The comprehensive sampling and granularity of collection provides power for revealing analyses of the relationship between nutritional quality and marketing of branded foods, timely observation of product reformulation and other changes to the Canadian food supply.

Benchmarking as a Public Health Strategy for Creating Healthy Food Environments: An Evaluation of the INFORMAS Initiative (2012-2020)

Diet-related noncommunicable diseases (NCDs) and obesity are the leading contributors to poor health worldwide. Efforts to improve population diets need to focus on creating healthy food environments. INFORMAS, established in 2012, is an international network that monitors and benchmarks food environments and related policies. By 2020, INFORMAS was active in 58 countries; national government policies were the most frequent aspect benchmarked. INFORMAS has resulted in the development and widespread application of standardized methods for assessing the characteristics of food environments. The activities of INFORMAS have contributed substantially to capacity building, advocacy, stakeholder engagement, and policy evaluation in relation to creating healthy food environments. Future efforts to benchmark food environments need to incorporate measurements related to environmental sustainability. For sustained impact, INFORMAS activities will need to be embedded within other existing monitoring initiatives. The most value will come from repeated assessments that help drive increased accountability for improving food environments.

Changes in the Sodium Content of Foods Sold in Four Latin American Countries: 2015 to 2018

In 2015, the Pan American Health Organization (PAHO) published sodium targets for packaged foods, which included two distinct levels: one “regional” and one “lower” target. Changes to the sodium content of the food supply in Latin American Countries (LAC) has not been evaluated. A repeated cross-sectional study used food label data from 2015 (n = 3859) and 2018 (n = 5312) to determine changes in the proportion of packaged foods meeting the PAHO sodium targets and the distribution in the sodium content of foods in four LAC (Argentina, Costa Rica, Paraguay, Peru). Foods were classified into the 18 food categories in the PAHO targets. The proportion of foods meeting the regional targets increased from 82.9% to 89.3% between 2015 and 2018 (p < 0.001). Overall, 44.4% of categories had significant decreases in mean sodium content. Categories with a higher proportion of foods meeting the regional and lower targets in 2018 compared to 2015 (p < 0.05) were breaded meat and poultry, wet and dry soups, snacks, cakes, bread products, flavored cookies and crackers, and dry pasta and noodles. While positive progress has been made in reducing the sodium content of foods in LAC, sodium intakes in the region remain high. More stringent targets are required to support sodium reduction in LAC.

Sodium Content of Foods Sold in the Spanish Market. Results from the BADALI Project

High sodium/salt intake is a risk factor for Non-Communicable Diseases (NCDs). Excess sodium intake has been associated with high coronary heart disease, stroke and high blood pressure. The sodium daily intake is above the recommendations in the world as well as in Spain. Reducing salt content in processed foods and ready meals is one of the main strategies for reducing sodium intake. The aim of the present work is to characterise the presence of sodium in foods sold in the Spanish market. We also study a possible shift in sodium content in products over the last few years. For this purpose, 3897 products included in the BADALI food database were analysed, classified into 16 groups (G). We found that 93.3% of all foods displayed the sodium/salt content in the nutrition declaration. Meat-processed and derivatives (G8) had the highest mean and median values for sodium content, followed by snacks (G15) and sauces (G14). Only 12.7% of foods were sodium-free (≤5 mg/100 g or 100 mL), 32.4% had very low sodium (≤40 mg/100 g or 100 mL) and 48.2% were low in sodium (≤120 mg/100 g or 100 mL). On the contrary, 47.2% were high in sodium according to the Pan American Health Organisation Nutrient Profile Model (PAHO-NPM), while there were 31.9% according to the Chile-NPM. The agreement between the two NPMs was considered 'substantial' (κ = 0.67). When sodium content was compared over the years, no decrease was observed. This analysis was performed in the entire food population, by food group and in matched products. Therefore, more effort should be made by all parties involved in order to decrease the sodium/salt intake in the population.

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries

PURPOSE OF REVIEW

The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs).

RECENT FINDINGS

The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.