To understand the extent to which national salt reduction strategies in Malaysia and Mongolia were implemented and achieving their intended outcomes.

Multiple methods process evaluations conducted at the mid-point of strategy implementation, guided by theoretical frameworks.

Malaysia (2018–2019) and Mongolia (2020–2021).

Desk-based reviews of related documents, interviews with key stakeholders (n 12 Malaysia, n 10 Mongolia), focus group discussions with health professionals in Malaysia (n 43) and health provider surveys in Mongolia (n 12).

Both countries generated high-quality local evidence about salt intake and levels in foods and culturally specific education resources. In Malaysia, education and reformulation activities were delivered with moderate dose (quantity) but reach among the population was low. Within 5 years, Mongolia implemented education among schools, health professionals and food producers on salt reduction with high reach, but with moderate dose (quantity) and reach among the general population. Both countries faced challenges in implementing legislative interventions (mandatory salt labelling and salt limits in packaged foods) and both could improve the scaling up of their reformulation and education activities.

In the first half of Malaysia’s and Mongolia’s strategies, both countries generated necessary evidence and education materials, mobilised health professionals to deliver salt reduction education and achieved small-scale reformulation in foods. Both subsequently should focus on implementing regulatory policies and achieving population-wide reach and impact. Process evaluations of existing salt reduction strategies can help strengthen intervention delivery, aiding achievement of WHO’s 30 % reduction in salt intake by 2025 target.

To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers.

A qualitative study involving twenty-two focus group discussions and six in-depth interviews was conducted, recorded and transcribed verbatim. An inductive thematic analysis approach was employed to analyse the data.

Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online.

Focus group discussions were conducted among twenty-three street food vendors, twenty-one caterers and seventy-six consumers of various eateries. In-depth interviews were conducted among two street food vendors and four caterers, individually.

Consumers and food operators perceived a high-salt intake within Malaysia’s out-of-home food sectors. Food operators emphasised the necessity for a comprehensive salt reduction policy in the out-of-home sector involving all stakeholders. Consumers faced limited awareness and knowledge, counterproductive practices among food operators and challenges in accessing affordable low-Na food products, whereas food operators faced the lack of standardised guidelines and effective enforcement mechanisms and uncooperative consumer practices. Both groups expressed that food quality and price of salt were also the barriers, and they advocated for awareness promotion, enhanced regulation of manufactured food products and stricter enforcement targeting vendors. Consumers also suggested promoting and recognising health-conscious food premises, whereas food operators suggested on knowledge enhancement tailored to them, strategies for gaining consumers acceptance and maintaining food quality.

These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia’s out-of-home sectors.

This study aimed to fill the current gap in the understanding of the knowledge, attitudes and behaviours (KAB) related to dietary Na among adult residents in Singapore.

A cross-sectional online survey was conducted between October and December 2020 on 955 participants selected through random sampling.

The survey was conducted in Singapore.

Participants were recruited from the Singapore Population Health Study Online Panel.

Participants’ mean age was 46·6 ± 14·1 years old and 58 % of them were females. Most of the participants were Chinese (82·1 %), 10·5 % were Indian and 4·5 % were Malay. Findings from the weighted data showed that most participants were aware of the health impact of high Na consumption. However, many participants were unaware of the recommended intake for salt (68%) and Na (83%), had misconceptions, and were unable to correctly use food labels to assess NA content (69%). Findings also alluded to the presence of knowledge gaps in the sources of Na in their diet. While 59 % of the participants reported to be limiting their consumption of Na, many reported facing barriers such as not knowing how to limit their Na intake. Participants also felt that there were limited options for low-Na foods when eating out and were lacking awareness of low-Na products.

Findings highlighted substantial gaps in participants’ knowledge and skills in managing their Na consumption. This suggests the need for more public education and improvements in the food environment.

To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).

Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson’s ‘Health Policy Triangle’ to assess the role of context, content, process and actors on the implementation of salt policy.

Argentina, Mongolia, South Africa and Vietnam.

Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.

Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.

Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

To analyse the Na content of bread by comparing the amount of salt and Na among the label, laboratory analysis and international guidelines.

Ten selected bakeries provided 3239 randomly selected samples of bread, which were weighed on-site. Triplicate samples were retrieved from each bakery (thirty samples) for analysis. Bread production was observed, and ingredient labels were queried to determine salt weights, which were used for comparison with the laboratory analysis. Flame photometry and the method for chlorides were utilised for analysing Na. Laboratory findings were compared to nine different international nutritional guidelines for Na consumption.

Florianopolis, south of Brazil.

Ninety independent bakeries locally producing Portuguese rolls were queried; rolls from ten conveniently selected bakeries were retrieved for further analysis.

The average weight of the rolls was 50·2 ± 5·3 g. The average amount of salt (g) per roll, by laboratory and label analyses, was 0·69 ± 0·0 and 0·62 ± 0·1 g, respectively. The mean level of Na (mg) reported on nutrient labels (478·2 ± 93·4/100 g) was significantly lower than by laboratory analysis (618·2 ± 73·8/100 g), P < 0·001. There was a difference for Na in rolls produced in the bakeries considering the unit weight of rolls (P ≤ 0·001) per 100 g (P = 0·026) and the mode of production. The consumption of two averaged units of rolls was equivalent to 51·7 % of the Brazilian guideline daily amount for Na for children and 31 % for adults.

The nutrient labels underreported Na values. This study strengthens the importance of monitoring Na of breads in Brazil.

Globally, China is among the ‘saltiest’ nations. In order to support current nationwide salt reduction initiatives, we investigated Chinese consumers’ knowledge, beliefs and behaviours related to salt intake and salt reduction.

A cross-sectional face-to-face survey was carried out, focusing on salt knowledge, beliefs and behaviours related to salt intake and salt reduction, perceptions of salt reduction responsibility and support for different national strategies.

The survey was carried out in China mainland.

Consumers (n 2444) from six of seven major geographical regions in China participated in the survey. After data cleaning, a sample of 2430 was included in the final analysis.

A majority of Chinese consumers believed that salt added during home cooking was the biggest contributor to their salt intake. Knowledge gaps existed in the awareness of salt hidden in certain foods and flavouring products. Chinese consumers in general were interested in lowering their salt intake. They were aware of salt reduction tools, but the adoption level was low. Consumers expressed strong support for promotion of salt-restriction spoons and public education, but not fiscal policies (e.g. salt-related tax or subsidies). In terms of individual differences, education status demonstrated a substantial impact on salt reduction knowledge and behaviour.

There is still big room to ‘shake’ Chinese consumers’ salt habit. The present study provides important evidence and consumer insights to support China’s efforts to meet its salt reduction targets.

The current study investigated the impact of different front-of-pack messages on liking, salt perception and table salt use of salt-reduced soups over repeated consumption.

In a between-subjects design, participants consumed a chicken noodle soup five times over 3 weeks. Participants were assigned to one of five experimental conditions and were categorized into three ‘Interest in Salt Reduction’ groups based on their self-reported interest in salt reduction. They consumed a regular-salt soup or a 30 % salt-reduced soup, either with or without a front-of-pack message (nutritional, sensory or social based). Liking, salt perception and table salt use were measured at each consumption.

Central location test.

British consumers (n 493) aged 24–65 years.

The soups remained stable in liking over repeated consumption, with no significant differences between the experimental conditions. However, liking did differ among the different Interest in Salt Reduction groups: the ‘not aware, no action’ group liked salt-reduced soups with a nutritional message the most, whereas the ‘aware and action’ group liked salt-reduced soups with a social message the most. There was no change in the amount of table salt added as people got more familiar with the salt-reduced soups, suggesting a strong role for habit in table salt use.

It mattered whether consumers were thinking about reducing their salt intake or not: a communication message tailored to a country’s interest in reducing salt is recommended to motivate consumers to lower their salt intake.

As countries struggle to meet the set targets for population salt intake, there have been calls for more regulated approaches to reducing dietary salt intake. However, little is known about how the public perceives various salt reduction policies; an important line of investigation given that the implementation and success of these policies often depend on public sentiment. We investigated the attitudes and beliefs of consumers towards salt reduction and their support for thirteen different government-led salt reduction policies.

A cross-sectional online survey measured participants’ knowledge, beliefs and attitudes in relation to salt reduction.

The survey was carried out with participants from the Republic of Ireland.

Five hundred and one participants recruited via a market research agency completed the survey.

We found that the vast majority of participants supported eleven of the government-led salt reduction policies, which included measures such as education, labelling and salt restriction in foods (both voluntary and regulated, across a range of settings). The two proposed fiscal policies (subsidising low-salt foods and taxing high-salt foods) received less support in comparison, with the majority of participants opposed to a tax on high-salt foods. A series of multiple regressions revealed that individual attitudes and beliefs related to health and salt were stronger predictors of support than sociodemographic factors, lifestyle or knowledge.

The study provides an important evidence base from which policy makers may draw when making decisions on future policy steps to help achieve national salt targets.

To explore salt content in bread and to evaluate the feasibility of reducing salt contained in ‘pan francés’ bread.

The study had two phases. Phase 1, an exploratory phase, involved the estimation of salt contained in bread as well as a triangle taste test to establish the amount of salt to be reduced in ‘pan francés’ bread without detection by consumers. In Phase 2, a quasi-experimental, pre–post intervention study assessed the effects of the introduction of low-salt bread on bakery sales.

A municipal bakery in Miraflores, Lima, Peru.

Sixty-five clients of the bakery in Phase 1 of the study; sales to usual costumers in Phase 2.

On average, there was 1·25 g of salt per 100 g of bread. Sixty-five consumers were enrolled in the triangle taste test: fifty-four (83·1 %) females, mean age 58·9 (sd 13·7) years. Based on taste, bread samples prepared with salt reductions of 10 % (P=0·82) and 20 % (P=0·37) were not discernible from regular bread. The introduction of bread with 20 % of salt reduction, which contained 1 g of salt per 100 g of bread, did not change sales of ‘pan francés’ (P=0·70) or other types of bread (P=0·36). Results were consistent when using different statistical techniques.

The introduction of bread with a 20 % reduction in salt is feasible without affecting taste or bakery sales. Results suggest that these interventions are easily implementable, with the potential to contribute to larger sodium reduction strategies impacting the population’s cardiovascular health.

The present study investigated the impact of salt labelling and repeated in-home consumption on liking of reduced-salt soups.

Participants received a chicken noodle soup to be consumed twice weekly at home for 5 weeks. Three soups were included: (i) regular-salt soup as available on the market; (ii) 22 %-reduced-salt soup; and (iii) 32 %-reduced-salt soup. The soups were tasted blind or with the label: ‘same great taste, less salt and more herbs’. In total, there were six experimental groups. All groups received the same soup over the whole period. Desire and liking were measured at each time of consumption.

In-home and central location test.

French consumers (n 646).

There was no significant difference in liking between the three soups when consumed at home, whereas the reduced-salt soups were less liked than the regular-salt soup in the central location test. Labelling did not boost liking scores, which is probably explained by the fact that all soups were similarly liked when eaten at home.

The surprising results of the present study in France suggest that a salt reduction of up to 32 % in a chicken noodle soup did not affect long-term liking score as assessed by consumers at home. In addition, initial liking measured at the central location was not predictive of liking after repeated in-home consumption. How far we can go in reducing salt in other products without compromising product quality, and how this impacts consumers’ choice behaviour and in turn table salt use at home, are still unanswered questions.

To describe the UK Food Standards Agency's (FSA) salt reduction programme undertaken between 2003 and 2010 and to discuss its effectiveness.

Relevant scientific papers, campaign materials and evaluations and consultation responses to the FSA's salt reduction programme were used.

Adult salt intakes, monitored using urinary Na data collected from UK-wide surveys, indicate a statistically significant reduction in the population's average salt intake from 9·5 g/d in 2000–2001 to 8·6 g/d in 2008, which is likely to have health benefits.

Reducing salt intake will have an impact on blood pressure; an estimated 6 % of deaths from CHD in the UK can be avoided if the number of people with high blood pressure is reduced by 50 %.

Salt levels in food, monitored using commercial label data and information collected through an industry self-reporting framework, indicated that substantial reductions of up to 70 % in some foods had been achieved. The FSA's consumer campaign evaluation showed increased awareness of the benefits of reducing salt intake on health, with 43 % of adults in 2009 claiming to have made a special effort to reduce salt in their diet compared with 34 % of adults in 2004, before the campaign commenced.

The UK's salt reduction programme successfully reduced the average salt intake of the population and increased consumers’ awareness. Significant challenges remain in achieving the population average salt intake of 6 g/d recommended by the UK's Scientific Advisory Committee on Nutrition. However, the UK has demonstrated the success of its programme and this approach is now being implemented elsewhere in the world.

To estimate the impact of choosing food products labelled either as low or high in salt on salt intake in the Finnish adult population.

The National FINDIET 2002 survey with 48-hour recalls from 2007 subjects aged 25–64 years. Sodium intake was calculated based on the Fineli® food composition database including the sodium content of natural and processed foods as well as the salt content of recipes. The distribution of salt intake was calculated in different ways: the present situation; assuming that all breads, cheeses, processed meat and fish, breakfast cereals and fat spreads consumed would be either ‘lightly salted’ or ‘heavily salted’ based on the current labelling practice; and, in addition, assuming that all foods would be prepared with 50% less or more salt.

Excluding underreporters, the mean salt intake would be reduced by 1.8 g in men and by 1.0 g in women if the entire population were to choose lightly salted products and further by 2.5 and 1.8 g, respectively, if also salt used in cooking were halved. Choosing heavily salted products would increase salt intake by 2.1 g in men and by 1.4 g in women. In the worst scenarios, salt intake would be further increased by 2.3 g in men and by 1.6 g in women.

These calculations show that the potential impact of labelling and giving consumers the possibility to choose products with less salt is of public health importance. In addition, strategies to reduce the salt content of all food groups are needed.