The path to eating less salt to save lives is clear but country uptake is patchy: Professor Jacqui Webster

About two million deaths per year globally can be attributed to people eating more than the World Health Organization’s (WHO) recommended daily salt intake of less than 5g/day. Eating too much salt increases blood pressure, a leading risk factor for premature death from cardiovascular disease, the world’s biggest killer.

Strong evidence shows that reducing population salt intake lowers blood pressure and that salt reduction strategies are an extremely cost-effective way to reduce the burden of chronic diseases. In 2011, the United Nations established a global target for all countries to reduce salt by 30 percent by 2025, as part of a range of targets to prevent and control non-communicable diseases.

Government-led strategies to reduce salt, if implemented effectively, have the potential to save millions of lives. In May 2021, the WHO launched global sodium benchmarks to encourage countries to turbo-charge salt reduction efforts, providing a level playing field for countries and food companies to reduce the salt content of foods contributing to excess salt in the diet.

A missed opportunity

Globally we should and could be doing much better. Our latest review of national salt reduction interventions showed that 96 countries now have some sort of strategy to reduce population salt intake, up from 75 in 2015.

However, when we looked closely at the data, implementation of these strategies is patchy, with very few countries having comprehensive salt reduction programs, combining working to get the food industry to reduce salt levels in foods and meals with education programs to get consumers to eat less salt.

Even more concerning is that only 17 countries have managed to achieve reductions in population salt intake to date. And very few of those are low- and middle-income countries where the burden of cardiovascular disease, high blood pressure and other chronic diseases and conditions is often greater. 

One proven effective strategy is when food companies reformulate their products. Yet disappointingly, our recent research in Australia, where there is an established government-led reformulation strategy, shows that not nearly enough companies are complying. This new research revealed that around 300 deaths a year could be avoided if just five Australian food manufacturers cut salt in packaged foods such as processed meat, bread, chicken nuggets and sausages down to government target levels; that if all companies complied with the Australian government’s new sodium targets, over 500 deaths could be prevented each year; and, if Australia had the same targets already in place in the UK, that could increase to another 660 deaths prevented.

The story is similar in other countries. In a separate multi-country study our researchers showed wide variation in salt content across processed fish and meat products, offering opportunities to reduce salt and meet WHO targets. Of the five countries studied, China had the highest amount of salt in both processed meat and fish products. The United States was second, followed by South Africa, Australia, and the UK.

Why are countries lagging in progress?

We recently completed a report  identifying existing barriers and opportunities for implementing effective salt reduction strategies to help understand how best to strengthen program implementation. The in-depth qualitative research was conducted in Argentina, Mongolia, South Africa, and Vietnam. Whilst no country had a co-ordinated comprehensive strategy to reduce salt, all four countries were taking action to get the food industry to reduce salt in foods.

There were key differences in approach: Argentina and South Africa had established mandatory targets compared to Vietnam and Mongolia which were taking a voluntary approach. Countries had mixed views about the potential benefits of reduced sodium salts (salt substitutes). And none of the countries had at that stage (2018) achieved a reduction in population salt intake, so there is clearly a need for more innovative interventions to support low- and middle-income countries to do better.

The untapped potential of salt substitutes

A second proven strategy for reducing population salt intake is the use of salt substitutes, which have the potential to deliver life-saving benefits in all countries. In high-income countries such as Australia, the US and the UK -where the majority of salt comes from processed foods and meals - the food industry can use salt substitutes to replace some of the sodium in these products. In countries where most of the salt is added during cooking or at the table, reduced sodium salts can be used by consumers directly in place of regular salt.

A variety of research has demonstrated that reduced sodium salts are an effective way of reducing blood pressure, in different countries and settings. However, a recent landmark study by The George Institute goes one step further, showing that replacing table salt with a reduced-sodium, added-potassium ‘salt substitute’ significantly reduces rates of stroke, heart attack and death. This is a game changer for salt reduction programs around the world, with the potential to save millions of lives.

So, what next?

The question now is not whether we should be implementing interventions to reduce population salt intake, but how do we do this effectively, at a country and global scale. In addition to adopting the WHO sodium benchmarks, countries need:

1. Reliable local data about the main sources of salt in the diet, so they know which foods and products to target - comprehensive surveys of diet and food composition will help to understand where people are getting their salt from.
2. Collaborative multi-sectoral implementation of evidence-based salt reduction strategies - strategies need to be adapted to the country context and implemented by government, industry, and local partners.
3. Stronger government leadership and regulatory processes, for example establishing targets and introducing salt substitutes - voluntary initiatives ultimately fail and so government regulation is essential.
4. Adequate resources for implementation and monitoring of strategies - this includes people and money to support regular collection and analysis of data.

The COVID-19 pandemic has highlighted the tremendous global burden of chronic diseases and conditions, a problem that is not going away any time soon. It has also shown us that the global community can work together quickly to save lives. The same determination is now needed to tackle chronic diseases and conditions, and action on salt is key.