From ancient of days, sodium chloride, popularly known as salt, has been used as a food flavour enhancer, turning otherwise insipid and unpalatable foods into opulent treats. Nonetheless, the European Food Safety Authority (EFSA) estimates that over 75% of the salt we consume comes from the foods we purchase, leading to excessive salt consumption.

The World Health Organization (WHO) has also noted with concern that the global average daily salt intake is more than double its recommended levels, placing the world off-course to meeting its 2025 goal of a 30% reduction in sodium intake. As a result, it has urged Member States to swiftly implement rules to reduce sodium intake and lessen the negative effects of excessive salt intake. The WHO has also called on food manufacturers to set ambitious salt reduction targets for their products.

“In 2013 all 194 WHO Member States committed to reducing the population’s sodium intake by 30% by the year 2025. Since then, progress has been slow and only a few countries have been able to reduce sodium intake. But then again, no one has been able to achieve the target. As such, it is being considered to extend the target to 2030,” said Dr. Francesco Branca, MD, Ph.D., Director, Department of Nutrition for Health and Development (NHD) at WHO.

Maximum allowable limits

The Organization recommends fewer than 5 grams (one teaspoon) of salt per day, whereas the average salt intake worldwide is estimated to be 10.8 grams per day. Table salt (sodium chloride) is the primary source of sodium, however, it can also be found in other condiments like sodium glutamate. Salt in the diet can come from processed foods, either because they are particularly high in salt (such as ready meals, processed meats like bacon, ham and salami, cheese, salty snack foods, and instant noodles, among others) or because they are consumed frequently in large amounts (such as bread and processed cereal products). Salt is also added to food during cooking (bouillon and stock cubes) or at the table (soy sauce, fish sauce, and table salt).

Even while sodium is a necessary nutrient, says WHO, excessive salt intake is the key risk factor for food and nutrition-related mortality. It is becoming more and more clear that eating a lot of sodium increases the risk of developing other illnesses like obesity, osteoporosis, kidney disease, and stomach cancer.

Implementation status of Member States

An estimated 7 million lives could be saved worldwide by the implementation of highly cost-effective salt reduction strategies by 2030, which is an important component of action to achieve the Sustainable Development Goal (SDG) target of reducing deaths from noncommunicable diseases. Yet, only nine nations (Brazil, Chile, Czech Republic, Lithuania, Malaysia, Mexico, Saudi Arabia, Spain, and Uruguay) now have a complete set of recommended policies to lower sodium intake.

According to the WHO report, 73% of WHO Member States do not fully implement these policies. A further 22% of Member States (43) have put at least one required policy or measure into effect. While 29% (56) of the remaining Member States have made a policy commitment to reducing sodium intake, 33% of them (64) have adopted at least one voluntary policy and other measures to do so.

Figure 4. Proportion of Member States implementing mandatory and/or voluntary sodium reduction policies and other measures (Page 14)

“Unhealthy diets are a leading cause of death and disease globally, and excessive sodium intake is one of the main culprits. This report shows that most countries are yet to adopt any mandatory sodium reduction policies, leaving their people at risk of heart attack, stroke, and other health problems.

“WHO calls on all countries to implement the ‘Best Buys’ for sodium reduction, and on manufacturers to implement the WHO benchmarks for sodium content in food,” said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General.

Multifaceted approach needed

Adopting mandatory regulations and the four salt-related WHO “best buy” measures, which make a significant contribution to the prevention of noncommunicable illnesses, are part of a comprehensive approach to sodium reduction. These include reformulating foods to contain less salt, setting targets for the amount of sodium in foods and meals, and establishing public food procurement policies to limit salt or sodium-rich foods in public institutions such as hospitals, schools, workplaces, and nursing homes. It also involves front-of-package labeling that helps consumers select products lower in sodium and behaviour change communication, and mass media campaigns to reduce salt/sodium consumption.

Reformulation is more prevalent in the higher-income groups and is more frequently used in the WHO Eastern Mediterranean and European regions. The first reformulation regulations were put in place in the 1980s by various Member States, which set maximum allowable limits for the amount of sodium in products like bread, tomato sauces, and peanut butter. By 2013, when the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases was established and sodium in the food supply was advised to be reduced, over half of the Member States with mandatory or optional sodium reduction reformulation policies had implemented this.

In 2022, WHO developed benchmarks for sodium content in 18 food categories and called on food operators to implement them globally. It is once again encouraging these countries to utilize the policies to set sodium content targets. Mandatory salt reduction programs are thought to be more effective because they attain wider coverage, protect against commercial interests, and give food manufacturers an equal playing field.

With only a national policy commitment to reduce sodium intake and no additional voluntary or required actions, 26 member states in the region (55%) remain in score 1.


African countries fall behind the rimes

Meanwhile, as other regions make progress in the national commitments and policy implementation to cut sodium intake, the African region seems to be taking the tail end with no Member State having reached score 4 as shown in the Sodium Country Score Cards. To document progress made thus far, WHO developed a Sodium Country Score Card for Member States based on the type and number of sodium reduction policies they have in place.

Nevertheless, there is still hope for the continent as Seychelles recorded a score of 3 thanks to the implementation of a public food procurement and service policy that mandates standards for sodium content and having implemented mandatory declaration of sodium on pre-packaged food.

In 2008, Seychelles approved a National School Nutrition Policy that establishes requirements for school meals as well as guidelines for the serving of food at fundraisers, in tuckshops, and other events. The recommended salt intake for school-aged children is 210 mg/day for children in creche, 360 mg/day for children in primary school, and 480 mg/day for children in secondary school. The guidelines for school meals are that these should not contribute more than 30% of that amount.

No meals with low nutritional value should be offered or sold, according to the rules for tuckshops, fundraisers, and other events. In 2018, revisions were made to the tuckshop regulations to incorporate a traffic light system for easier categorization of foods and beverages with low, moderate, and high nutritional values.

The national government formulated an implementation guideline, along with a sample lease agreement for school tuckshops and a monitoring tool. Every school was required to have local school nutrition action groups, made up of a teacher, student, parent, tuckshop owner, dining staff member, school nurse, dental therapist, and district representative, who were responsible for monitoring. There are, however, very few schools where this group has been established and is still active, says the report.

Using the monitoring technology, central and local authorities also keep track of nutrition in schools at least once a year and communicate their findings to the management team of each relevant school.

Moreover, four other Member States have put mandatory measures into effect but do not entirely meet the criteria for scoring 3. Although not requiring a salt disclosure on every pre-packaged food item, Cabo Verde, Mauritius, and South Africa all have required regulations with an underlying nutrient profile model that includes sodium. Algeria, however, has no other obligatory requirements other than the mandatory salt declaration on pre-packaged food.

Ten Member States only have voluntary programs to reduce sodium and maintain a score of two. Countries like Algeria, Cabo Verde, Comoros, Eritrea, Gambia, Guinea, Madagascar, Mauritania, and South Africa have launched media campaigns to create awareness whereas Senegal has set voluntary reformulation targets.

In South Africa, the advocacy group Salt Watch was founded in 2014, funded, in part, by the National Department of Health through the Heart and Stroke Foundation South Africa. In addition to identifying items high in salt and the need to minimize sodium added during cooking and to food at the table, it was mandated to undertake a mass media campaign to raise public awareness about the relationship between high sodium intake, blood pressure, and cardiovascular disease.

The behavior change-based campaign featured a well-known South African medical professional and media figure. Following rigorous testing, the campaign ran for six months, airing on average 44 times on television and 131 times on radio each month. Activities to promote the campaign included the distribution of lower-sodium recipes, informational and educational materials, the Salt Watch website, and other resources to different venues and healthcare providers. The campaign also increased print and social media awareness and uptake. An assessment of the campaign revealed a considerable shift in behavior toward reducing salt consumption.

With only a national policy commitment to reduce sodium intake and no additional voluntary or required actions, 26 Member States in the Region (55%) remain in score 1. As a result, the African Region now has the greatest proportion of Member States that are only committed to national policy.

The status of the other ten member states; Angola, Botswana, Cameroon, Democratic Republic of the Congo, Congo, Equatorial Guinea, Guinea-Bissau, Liberia, Malawi, and South Sudan has either not been addressed or is unknown.

Table 1. Sodium reduction policies and other measures implemented in the African Region (pg 35)

Urgent action needed

With the feedback at hand, WHO has pledged to support Member States in their efforts to adopt, implement and monitor mandatory sodium reduction legislation. Moreover, according to the Organization, if all nations speed up the adoption of policies to assure the application of best practices and at least two required interventions, sodium intake could be significantly decreased by 2030.

“This important report demonstrates that countries must work urgently to implement ambitious, mandatory, government-led sodium reduction policies to meet the global target of reducing salt consumption by 2025.

“There are proven measures that governments can implement and important innovations, such as low sodium salts. The world needs action, and now, or many more people will experience disabling or deadly—but preventable—heart attacks and strokes,” said Dr. Tom Frieden, President and CEO of Resolve to Save Lives, a not-for-profit organization working with countries to prevent 100 million deaths from cardiovascular disease over 30 years.

This feature appeared in the March 2023 issue of Food Safety Africa. You can read the magazine HERE