Salt reduction

WHO Fact sheet Reviewed June 2016

Key facts

• High sodium consumption (>2 grams/day, equivalent to 5 g salt/day) and insufficient potassium intake (less than 3.5 grams/day) contribute to high blood pressure and increase the risk of heart disease and stroke.
• The main source of sodium in our diet is salt, although it can come from sodium glutamate, used as a condiment in many parts of the world.
• Most people consume too much salt—on average 9–12 grams per day, or around twice the recommended maximum level of intake.
• Salt intake of less than 5 grams per day for adults helps to reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart attack. The principal benefit of lowering salt intake is a corresponding reduction in high blood pressure.
• WHO Member States have agreed to reduce the global population’s intake of salt by a relative 30% by 2025.
• Reducing salt intake has been identified as one of the most cost-effective measures countries can take to improve population health outcomes. Key salt reduction measures will generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person.
• An estimated 2.5 million deaths could be prevented each year if global salt consumption were reduced to the recommended level.

Overview

Increasing production of more and more processed food, rapid urbanization, and changing lifestyles are transforming dietary patterns. Highly processed foods are increasing in availability and becoming more affordable. People around the world are consuming more energy-dense foods that are high in saturated fats, trans fats, sugars, and salt. Salt is the primary source of sodium and increased consumption of sodium is associated with hypertension and increased risk of heart disease and stroke.

At the same time, as their eating patterns shift, people are consuming less fruit vegetables and dietary fibre (such as whole grains), that are key components of a healthy diet. Fruits and vegetables contain potassium, which contributes to reduce blood pressure.

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).

However, some manufacturers are reformulating recipes to reduce the salt content of their products and consumers should read food labels and choose products low in sodium.

Recommendations for salt reduction

• For adults: WHO recommends that adults consume less than 5 g (just under a teaspoon) of salt per day¹.
• For children: WHO recommends that the recommended maximum intake of salt for adults be adjusted downward for children aged two to 15 years based on their energy requirements relative to those of adults. This recommendation for children does not address the period of exclusive breastfeeding (0–6 months) or the period of complementary feeding with continued breastfeeding (6–24 months).
• All salt that is consumed should be iodized or “fortified” with iodine, which is essential for healthy brain development in the fetus and young child and optimizing people’s mental function in general.

About salt, sodium and potassium

• Sodium is an essential nutrient necessary for maintenance of plasma volume, acid-base balance, transmission of nerve impulses and normal cell function.
• Excess sodium is linked to adverse health outcomes, including increased blood pressure.
• The primary contributors to dietary sodium consumption depend on the cultural context and dietary habits of a population.
• Sodium is found naturally in a variety of foods, such as milk, meat and shellfish. It is often found in high amounts in processed foods such as breads, processed meat and snack foods, as well as in condiments (e.g. soy source, fish source).
• Sodium is also contained in sodium glutamate, used as a food additive in many parts of the world.
• Potassium is an essential nutrient needed for maintenance of total body fluid volume, acid and electrolyte balance, and normal cell function.
• Potassium is commonly found in a variety of unrefined foods, especially fruits and vegetables.
• Increased potassium intake reduced systolic and diastolic blood pressure in adults.

How to reduce salt in diets

Government policies and strategies should create environments that enable populations to consume adequate quantities of safe and nutritious foods that make up a healthy diet including low salt. Improving dietary habits is a societal as well as an individual responsibility. It demands a population-based, multisectoral, and culturally relevant approach.

Key broad strategies for salt reduction include:

• government policies - including appropriate fiscal policies and regulation to ensure food manufacturers and retailers produce healthier foods or make healthy products available and affordable;
• working with the private sector to improve the availability and accessibility of low-salt products;
• consumer awareness and empowerment of populations through social marketing and mobilization to raise awareness of the need to reduce salt intake consumption;
• creating an enabling environment for salt reduction through local policy inter-ventions and the promotion of “healthy food” settings such as schools, workplaces, communities, and cities;
• monitoring of population salt intake, sources of salt in the diet and consumer knowledge, attitudes and behaviours relating to salt to inform policy decisions.

Salt reduction programmes and programmes that promote fortification with micronutrients of salt, condiments or seasonings high in salt (bouillon cubes, soy and fish sauce) can complement each other.

Salt consumption at home can be reduced by:

• not adding salt during the preparation of food;
• not having a salt shaker on the table;
• limiting the consumption of salty snacks;
• choosing products with lower sodium content.

Other local practical actions to reduce salt intake include:

• integrating salt reduction into the training curriculum of food handlers;
• removing salt shakers and soy sauce from tables in restaurants; Introducing product or shelf labels making it clear that certain products are high in sodium;
• providing targeted dietary advice to people visiting health facilities;
• advocating for people to limit their intake of products high in salt and advocating that they reduce the amount of salt used for cooking; and
• educating children and providing a supportive environment for children so that they start early with adopting low salt diets.

Actions by the food industry should include:

• incrementally reducing salt in products over time so that consumers adapt to the taste and don’t switch to alternative products;
• promoting the benefits of eating reduced salt foods through consumer awareness activities in food outlets;
• reducing salt in foods and meals served at restaurants and catering outlets and labelling sodium content of foods and meals.

Misperceptions about salt reduction

• “On a hot and humid day when you sweat, you need more salt in the diet:” There is little salt lost through sweat so there is no need for extra salt even on a hot and humid day, although it is important to drink a lot of water.
• “Sea salt is not ‘better’ than manufactured salt simply because it is ‘natural.’” Regardless of the source of salt, it is the sodium in salt that causes bad health outcomes.
• “Salt added during cooking is not the main source of salt intake.” In many countries, about 80% of salt in the diet comes from processed foods.
• “Food does not need salt to have appealing flavour.” It takes some time for a person’s taste buds to adjust, but once they get used to less salt, one is more likely to enjoy food and notice a broader range of flavours.
• “Food has no flavour without salt.” Whilst this may be true at first, taste buds soon become accustomed to less salt and you are more likely to enjoy food with less salt, and more flavour.
• “Foods high in salt taste salty.” Some foods that are high in salt don't taste very salty because sometimes they are mixed with other things like sugars that mask the taste. It is important to read food labels to find out sodium levels.
• “Only old people need to worry about how much salt they eat:” Eating too much salt can raise blood pressure at any age.
• “Reducing salt could be bad for my health:” It’s very difficult to eat too little salt since there are so many everyday foods containing salt.

WHO response

WHO guidelines on sodium and potassium provide thresholds for healthy intake. The guidelines also outline measures for improving diets and preventing NCDs in adults and children.

The “Global Strategy on Diet, Physical Activity and Health” was adopted in 2004 by the World Health Assembly (WHA). It calls on governments, WHO, international partners, the private sector and civil society to take action at global, regional and local levels to support healthy diets and physical activity.

In 2010, the WHA endorsed a set of recommendations on the marketing of foods and non-alcoholic beverages to children. These guide countries in designing new policies and strengthening existing ones to reduce the impact on children of the marketing of unhealthy food. WHO is also helping develop a nutrient profile model that countries can use as a tool to implement the marketing recommendations.

In 2011, world leaders committed to reducing people’s exposure to unhealthy diets. The commitment was made through a Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs.

In 2012, the WHA adopted six global nutrition targets, including the reduction of stunting, wasting and overweight in children, the improvement of breastfeeding and the reduction of anaemia and low birth weight.

In 2013, the WHA agreed 9 global voluntary targets for the prevention and control of NCDs, which include a halt to the rise in diabetes and obesity and a 30% relative reduction in the intake of salt by 2025. The "Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020" gives guidance and a menu of policy options for Member States, WHO and other UN agencies to achieve the targets.

With many countries now seeing a rapid rise in obesity among infants and children, WHO in May 2014 set up a commission on childhood obesity. The Commission will draw up a report for 2015 specifying which approaches and actions are likely to be most effective in different contexts around the world.

¹ These recommendations apply to all individuals, with or without high blood pressure (including pregnant and lactating women), except individuals with illnesses or those taking drug therapy that may lead to low sodium levels or acute build-up of body water, or require physician-supervised diets (e.g. patients with heart failure and those with type I diabetes). In these subpopulations, there may be a particular relationship between sodium intake and the health outcomes sought.(WHO. Guideline: Sodium intake for adults and children, 2012).