A Systematic Review of Salt Reduction Initiatives Around the World: A Midterm Evaluation of Progress Towards the 2025 Global Non-Communicable Diseases Salt Reduction Target

Abstract

In 2013, the WHO recommended that all member states aim to reduce population salt intake by 30% by 2025. The year 2019 represents the midpoint, making it a critical time to assess countries' progress towards this target. This review aims to identify all national salt reduction initiatives around the world in 2019, and to quantify countries' progress in achieving the salt reduction target. Relevant data were identified through searches of peer-reviewed and gray literature, supplemented with responses from prefilled country questionnaires sent to known country leads of salt reduction or salt champions, WHO regional representatives, and international experts to request further information. Core characteristics of each country's strategy, including evaluations of program impact, were extracted and summarized. A total of 96 national salt reduction initiatives were identified, representing a 28% increase in the number reported in 2014. About 90% of the initiatives were multifaceted in approach, and 60% had a regulatory component. Approaches include interventions in settings (n= 74), food reformulation (n = 68), consumer education (n = 50), front-of-pack labeling (n = 48), and salt taxation (n = 5). Since 2014, there has been an increase in the number of countries implementing each of the approaches, except consumer education. Data on program impact were limited. There were 3 countries that reported a substantial decrease (>2 g/day), 9 that reported a moderate decrease (1-2 g/day), and 5 that reported a slight decrease (<1 g/day) in the mean salt intake over time, but none have yet met the targeted 30% relative reduction in salt intake from baseline. In summary, there has been an increase in the number of salt reduction initiatives around the world since 2014. More countries are now opting for structural or regulatory approaches. However, efforts must be urgently accelerated and replicated in other countries and more rigorous monitoring and evaluation of strategies is needed to achieve the salt reduction target.

Keywords: food policy; noncommunicable diseases; public health nutrition; salt; salt intake; salt reduction; sodium.

FIGURE 1

Identification of national salt reduction strategies around the world.

FIGURE 2

Characteristics of national salt reduction initiatives around the world (n = 96). For IS, some countries implemented multiple initiatives in different settings. If at least 1 initiative is a procurement policy, then IS was marked as “YES (procurement policies)” in this figure. The same rule applies to FR and FOPL (if at least 1 initiative is mandatory). MOC refers to changes in either salt intake, salt levels in foods, or KAB towards salt, that were measured using the same methods (i.e., comparable methods of assessment over time). The specific activities for each implementation strategy per country, the details on the measures of change, and the sources of information are shown in Supplemental Table 2. Abbreviations: CE, consumer education; FOPL, front-of-pack labeling; FR, food reformulation; IS, interventions in settings; KAB, knowledge, attitudes, and behaviors; MOC, measure of change; TAX, salt taxation.

FIGURE 3

Summary of progress in implementing salt reduction initiatives since 2014.

FIGURE 4

Summary of progress in implementing salt reduction initiatives by WHO region. Abbreviations: AFRO, Regional Office for Africa; AMRO, Regional Office for the Americas; CE, consumer education; EMRO, Regional Office for the Eastern Mediterranean; EURO, Regional Office for Europe; FOPL, front-of-pack labeling; FR, food reformulation; IS, intervention in settings; SEARO, Regional Office for Southeast Asia; TAX, salt taxation; WPRO, Regional Office for the Western Pacific.

FIGURE 5

Summary of progress in implementing salt reduction initiatives by income classification. Abbreviations: CE, consumer education; FOPL, front-of-pack labeling; FR, food reformulation; IS, intervention in settings; TAX, salt taxation.