The World Health Organization recommends a daily salt intake of less than 5.0 g. Similarly, Malaysia's Salt Reduction Strategy to Prevent and Control Non-communicable Diseases (2021-2025) targets a daily intake of less than 6.0 g by 2025, achievable through salt reduction in processed and prepared foods. However, the lack of maximum salt targets for food businesses to adhere to, poses a potential challenge to the effectiveness of salt reduction efforts. This paper presents a step-wise approach to propose maximum salt targets in key food categories, paving the way for mandatory or voluntary policy interventions. Following a step-wise approach by Downs et al. (2015) for setting national salt targets, this study systematically proposed maximum salt targets for selected food categories. Steps included: (1) identifying major contributors to dietary salt; (2) selecting target food categories; and (3) establishing target levels. Steps 1 and 2 were performed by reviewing literature from local dietary survey and analyzing street food nutrient content as well as retrieving secondary data from previous market surveys. An additional market survey was conducted in February 2024 following the gazettement of mandatory sodium labelling in January 2024. Scatter plot analysis, literature reviews and expert consultations were used to achieve Step 3. Step 1 identified that the major contributors to Malaysia's salt intake are cooked food and processed foods. A total of 14 food categories under the Food Regulation 1985 were selected for target setting based on their contribution to dietary salt intake and relevance to ongoing revision in the Malaysia Food Act 1983 (Step 2). The 75th percentile sodium level was selected as the maximum salt target and adjusted by a further 10-20% reduction based on sales data from a reputable source (Step 3). This study proposed maximum salt targets for 14 food categories, which are recognised as major contributors to salt intake in Malaysian diets. There is a need to further engage with stakeholders and develop monitoring mechanisms to support the implementation of maximum salt targets as well as evaluating consumer behaviour changes.

Objectives:To test the hypothesis that the association of formula-estimated sodium intake from spot urine with cardiovascular disease is independent of spot urinary sodium concentration.Methods:We included 435 336 participants in the UK Biobank whose sodium intake was estimated from spot urine using INTERSALT, Kawasaki, and Tanaka formulas. Hazard ratios for cardiovascular disease (CVD) events and deaths were estimated using Cox proportional-hazard model adjusted for multiple covariates. Penalized Cox regression was used to assess nonlinear relations. Hazard ratios were recalculated after replacement of the sodium concentration term with sex-specific mean values (women: 67.5 mmol/l; men: 89.8 mmol/l) to assess how other components of the formulas influenced these associations.Results:Forty-four thousand two hundred and sixty-eight CVD events and 3251 CVD deaths occurred during a median follow-up of 12 years. The mean estimated sodium intake was 143 (SD = 35), 178 (52), and 147 (33) mmol/day based on INTERSALT, Kawasaki, and Tanaka formulas, respectively. For CVD incidence, linear inverse associations were observed for INTERSALT and Tanaka estimates [hazard ratios (95% CIs) for every 50 mmol increase in estimated sodium intake: 0.9 (0.83-0.97) and 0.93 (0.89- 0.97); P-linear = 0.0047 and 0.0021], and a U-shaped association for the Kawasaki estimates (P-nonlinear = 0.0026). When the sodium concentration term was fixed, inverse associations were seen for all formulas [0.86 (0.77-0.95), 0.96 (0.93-0.99) and 0.94 (0.89-0.99) for INTERSALT, Kawasaki, and Tanaka; P linear = 0.0054, 0.0166 and 0.0188]. For CVD mortality, no association was observed, but a nonlinear association was identified for the INTERSALT equation (P-nonlinear = 0.0287) after fixing the sodium concentration.Conclusion:These formula-estimated sodium intakes were associated with CVD incidence and mortality independently of spot urinary sodium concentration. We recommend these formulas not be used in studies associating sodium intake with CVD outcomes to avoid generating misleading evidence.

BACKGROUND: Both blood pressure–lowering medication and sodium reduction are effective in hypertension control, but whether blood pressure–lowering medication modifies the effect of sodium reduction is unclear. This study aims to evaluate the dose-response effect of sodium intake reduction on blood pressure in treated hypertensive individuals and the impact of different classes of blood pressure–lowering drugs. METHODS: We searched multiple databases and reference lists up to July 9, 2024. Randomized controlled trials with a duration of ≥2 weeks comparing the effect of different levels of sodium intake (measured by 24-hour urinary sodium excretion) on blood pressure in hypertensive individuals treated with constant blood pressure–lowering medications were included. Instrumental variable meta-analyses based on random effects models were conducted to evaluate the dose effect of sodium reduction on blood pressure. Subgroup analyses were performed based on the class of blood pressure–lowering drugs. RESULTS: We included 35 studies (median duration of 28 days) with a total of 2885 participants. For every 100 mmol reduction in 24-hour urinary sodium excretion, systolic blood pressure decreased by 6.81 mm Hg (95% CI, 4.96–8.66), diastolic blood pressure decreased by 3.85 mm Hg (95% CI, 2.26–5.43), and mean arterial pressure decreased by 4.83 mm Hg (95% CI, 3.22–6.44). The dose-response effects varied across classes of blood pressure–lowering medications, with greater effects observed in the β-blockers, renin-angiotensin-aldosterone system inhibitors, and dual therapy groups. No significant subgroup differences were observed based on age, baseline 24-hour urinary sodium excretion, blood pressure levels, or study duration. CONCLUSIONS: Pooled evidence suggests a dose-response relationship between sodium reduction and blood pressure in treated individuals with hypertension, influenced by the class of blood pressure–lowering medications.

Objective: To evaluate the dose-response effects of a reduction in dietary sodium intake on blood pressure (BP) in hypertensive individuals who were on antihypertensive treatments. The impact of antihypertensive-drug class was also examined. Design and method: We searched Medline (via Ovid), Embase, Scopus, Cochrane Central Register of Controlled Trials, and reference lists of relevant articles up to 12 November 2023. We included randomised controlled trials (RCTs) comparing the effect on BP between different levels of dietary sodium intake in adults who were diagnosed as primary hypertension and treated with constant antihypertensive medications during the study period. We excluded RCTs with duration < 2 weeks. Dietary sodium intake was measured using 24-hour urinary sodium excretion. Instrumental variable meta-analyses were conducted to evaluate the dose-response effects of sodium reduction on BP. Subgroup analysis and multivariate meta-regression analysis were performed to examine the impact of antihypertensive-drug class. Results: 35 studies with 2885 participants were included. The pooled estimates of mean reduction in 24-hour urinary sodium excretion, systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) were 68.74 (95% confidence interval: 62.30-75.19) mmol, 4.33 (3.37-5.29) mmHg, 2.60 mm Hg (2.04-3.17), and 3.19 (2.50-3.87), respectively. For every 100 mmol reduction in 24-hour urinary sodium excretion, SBP, DBP, and MAP decreased by 6.81 (4.96-8.66) mmHg, 3.85 (2.26-5.43) mmHg, and 4.83 (3.22-6.44) mmHg, respectively (Fig 1). The observed dose-response effects differed across class of antihypertensive medication (P-diff = 0.084 for SBP, and P-diff<0.05 for DBP and MAP). In Beta-blockers, Renin-Angiotensin-Aldosterone System (RAAS) inhibitors, and dual therapy groups, significant dose-response effects of sodium on SBP, DBP and MAP were observed. In Calcium Chanel Blockers (CCB) group, the dose-response relationship was only found for SBP. No dose-response effect on BP was observed in diuretics monotherapy group. Conclusions: Pooled evidence of RCTs suggests a dose-response relationship between sodium reduction and BP in treated hypertensives, which is impacted by class of antihypertensive medications.

Objectives: Observational studies that assess the relationship between salt intake and long-term outcomes require a valid estimate of usual salt intake. The gold-standard measure in individuals is sodium excretion in multiple nonconsecutive 24-h urines. Multiple studies have demonstrated that random spot urine samples are not valid for estimating usual salt intake; however, some researchers believe that fasting morning spot urine samples produce a better measure of usual salt intake than random spot samples. Methods: We have used publicly available data from a PURE China validation study to compare estimates of usual salt intake from morning spot urine samples and three published formulae with mean of two 24-h urine samples (reference). We estimated the means and 95% confidence intervals of absolute and relative errors for each formula-led method and the degree to which estimates were able to be classified into the correct quartile of intake. Bland-Altman plots were used to test the level of agreement. Results: The results show that compared with the reference method, all formulae-led estimates from spot urine collections have high error rates: both random and systematic. This is demonstrated for individual estimates, as well as by quartiles of reference salt intake. This study conclusively demonstrates the unsuitability of morning spot urine formula-led estimates of usual salt intake. Conclusion: Our findings support international recommendations to not conduct, fund, or publish research studies that use spot urine samples with estimating equations to assess individuals’ salt intake in association with health outcomes.

Poor diets are the major cause of death and disease globally, driving high levels of obesity and noncommunicable diseases. Cheap, heavily marketed, ultra-processed, energy-dense and nutrient-poor food and drinks that are high in fat, sugar and salt play a major role. The high-sugar content of these products leads to consumption levels much higher than recommended. The World Health Organization recommends that sugar intake should be reduced to just 5% of energy intake by using fiscal policies and food and drink reformulation strategies. Over the previous decade, the government of the United Kingdom of Great Britain and Northern Ireland has implemented several policies aimed at reducing sugar intake. We compare the soft drinks industry levy and the sugar reduction programme, examining how differences in policy design and process may have influenced the outcomes. Success has been mixed: the mandatory levy achieved a reduction in total sugar sales of 34.3%, and the voluntary reduction programme only achieved a 3.5% reduction in sugar levels of key contributors to sugar intake (despite a target of 20%). Both policies can be improved to enhance their impact, for example, by increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and by setting more stringent subcategory specific targets in the sugar reduction programme. We also recommend that policy-makers should consider applying a similar levy to other discretionary products that are key contributors to sugar intake. Both approaches provide valuable learnings for future policy in the United Kingdom and globally.

Carefully reviewed extensive evidence supports the lowering of dietary sodium for cardiovascular health [1]. This is reflected in dietary guidance worldwide [1]. For example, the WHO recommends that adults limit their sodium intake to less than 2 g/day (equivalent to 5 g/day of salt) [1]. Despite this, there continues to be a controversial argument that it may be unsafe to lower dietary sodium. In this editorial, we briefly discuss the basis of this narrative and propose a more scientifically sound perspective that questions the safety of adding sodium to foods at levels that substantively increase dietary sodium. The international observational Intersalt study showed that higher sodium intake was associated with higher blood pressure and increased blood pressure with age. Intersalt and other studies have identified several populations that consume very little salt and natural foods that have very little sodium [2]. Hunter-gatherer populations that only eat natural foods without added sodium generally consume less than 700 mg sodium/day with vegetarian diets containing less than 500 mg sodium/day [1,2]. Most hunter gather diets contained 100–700 mg sodium/day [1,2]. Hypertension is rare and increases in blood pressure with age do not occur in populations with diets under 1000 mg sodium/day. Atherosclerotic and hypertensive cardiovascular diseases did not occur in hunter-gatherer populations [1,2]. Current diets contain vast amounts of sodium, which is added during the commercial and home processing of foods [1]. Commercially added sodium is the dominant dietary source in industrialized countries, whereas sodium added at home remains an important source in the few countries that have not undergone nutritional transition [3]. Countries undergoing nutrition transition usually have both home and commercial sources and the highest average dietary sodium intake (e.g. China) [3]. A dose–response relationship between sodium intake and blood pressure has been confirmed in multiple randomized controlled trials [4]. Randomized controlled trials have shown approximately linear increases in blood pressure as dietary sodium increases above 800 mg/day [1,4]. The trials did not define a lower threshold at which dietary sodium intake did not increase blood pressure. A meta-analysis of randomized controlled trials with posttrial follow-up reported a 26% reduction in cardiovascular disease with a modest average decrease in dietary sodium (3642–2690 mg/day) and a linear association between cardiovascular disease and dietary sodium within the limits of the trial data (2300–4100 mg/day) [1,5]. Similarly, a meta-analysis of cohort studies that assessed dietary sodium using the recommended standard of multiple nonconsecutive 24 h urine collections found a linear association between dietary sodium and cardiovascular disease within the range of the study data (1846–5230 mg/day) [1,6]. These studies did not define a lower threshold at which dietary sodium did not increase cardiovascular disease or mortality. Conversely, low-quality observational data have shown increased cardiovascular disease with dietary sodium below 3000 mg/day [7,8]. A substantial proportion of the studies include assessing dietary sodium with spot urine samples and estimating equations that have been shown to produce false associations with health outcomes, and hence have been strongly recommended not to be used by national and international scientific organizations [9]. Studies have also included populations that include people with diseases where reverse causality (people who are ill are likely to eat less sodium) as well as indication bias (people with hypertension and cardiovascular disease may be prescribed lower sodium diets) could be expected to cause an inverse association between dietary sodium and cardiovascular disease. For some controversial and widely cited studies, particularly the Prospective Urban Rural Epidemiology (PURE) study, access to data for external independent verification has been repeatedly declined [7,8,10]. For decades, controversial low-quality research results have been highly promoted by the food and salt industry, scientists conducting studies, and several scientists and clinicians with financial conflicts of interest, including overt funding from the salt and food industries and membership in their advisory boards [7,8]. The salt and food industries have also questioned the validity of studies demonstrating the benefits of lowering sodium intake [11]. Low-quality studies have results that are not reliable or reproducible, and most are incompatible with higher quality, more rigorous research. Nevertheless, low-quality studies continue to be conducted with investigators defending the methods because they are 'feasible' (i.e. 'easy to do') [12]. Extensive misinformation (false and misleading statements), based in part on low-quality research, is generated by the food sector and often financially conflicted scientists and clinicians [7,8,10]. In the past, mainstream scientific organizations have often disregarded the balance of evidence provided by extensive and repeated reviews by highly regarded unbiased scientific organizations [1,8]. Controversial low-quality research has been extensively presented and highlighted at meetings and in lay and scientific publications, creating controversy. This has created the common current perception that the scientific community needs to be concerned about the harm from reducing dietary sodium and performing randomized controlled trials with the null hypothesis being that lowering dietary sodium causes cardiovascular disease [13]. Cardiovascular disease is the leading cause of death worldwide [14]. Approximately 30% of hypertension cases are attributed to high dietary sodium [1]. Currently, increased blood pressure affects more than one-quarter of adults and is the leading global risk factor for death [1,14]. Increases in dietary sodium cause hypertension and cardiovascular disease, without a defined lower limit of sodium in the diet that causes harm. The most scientifically valid null hypothesis, therefore, is that adding sodium to food causes increases in blood pressure and increases in cardiovascular disease. In the absence of clinical trial data to support the safety of adding sodium to food, efforts to reduce dietary sodium must be markedly increased. ACKNOWLEDGEMENTS Conflicts of interest N.R.C.C. reports personal fees from Resolve to Save Lives (RTSL), the Pan American Health Organization, and the World Bank outside the submitted work; and is an unpaid member of the World Action on Salt, Sugar, and Health and an unpaid consultant on dietary sodium and hypertension control to numerous governmental and nongovernmental organizations. N.R.C.C. was on the Medical Advisory Board of Switch Health (2022–2023) and was a one-time reviewer of a joint Novartis Canada Alberta Health Services collaborative project to treat dyslipidaemia. All honoraria from Switch Health and Novartis Canada were donated to the University of Calgary to support a community cardiovascular disease prevention recognition award. F.J.H. is an unpaid member of Action on Salt and World Action on Salt, Sugar and Health (WASSH). G.A.M. is the unpaid Chair of Action on Salt, Action on Sugar, WASSH and Blood Pressure UK. R.M.M. reports no conflicts of interest.

Cardiovascular diseases (CVDs) are the major cause of death among Malaysians. Reduction of salt intake in populations is one of the most cost-effective strategies in the prevention of CVDs. It is very feasible as it requires low cost for implementation and yet could produce a positive impact on health. Thus, salt reduction initiatives have been initiated since 2010, and two series of strategies have been launched. However, there are issues on its delivery and outreach to the target audience. Further, strategies targeting out of home sectors are yet to be emphasized. Our recent findings on the perceptions, barriers and enablers towards salt reduction among various stakeholders including policy-makers, food industries, food operators, consumers and schools showed that eating outside of the home contributed to high salt intake. Foods sold outside the home generally contain a high amount of salt. Thus, this supplementary document is being proposed to strengthen the Salt Reduction Strategy to Prevent and Control Non-communicable Diseases (NCDs) for Malaysia 2021-2025 by focussing on the strategy for the out-of-home sectors. In this supplementary document, the Monitoring, Awareness and Product (M-A-P) strategies being used by the Ministry of Health (MOH) are adopted with a defined outline of the plan of action and indicators to ensure that targets could be achieved. The strategies will involve inter-sectoral and multi-disciplinary approaches, including monitoring of salt intake and educating consumers, strengthening the current enforcement of legislation on salt/sodium labelling and promoting research on reformulation. Other strategies included in this supplementary document included reformulation through proposing maximum salt targets for 14 food categories. It is hoped that this supplementary document could strengthen the current the Salt Reduction Strategy to Prevent and Control NCDs for Malaysia 2021-2025 particularly, for the out-of-home sector, to achieve a reduction in mean salt intake of the population to 6.0 g per day by 2025.

IMPORTANCE Soft drink consumption is associated with weight gain in children and adolescents, but little is known about the association between soft drink consumption and prevalence of the overweight and obesity in adolescents. OBJECTIVE To investigate the association of soft drink consumption with overweight and obesity in adolescents enrolled in school (hereafter, school-going adolescents) using country-level and individuallevel data. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from 3 cross-sectional studies including 107 countries and regions that participated in the Global School-Based Student Health Survey (2009-2017), the European Health Behavior in School-Aged Children study (2017-2018), and the US Youth Risk Behavior Survey (2019). EXPOSURE Daily soft drink consumption (consuming soft drinks 1 or more times per day or not). MAIN OUTCOME AND MEASURE Overweight and obesity defined by theWorld Health Organization Growth Reference Data. RESULTS Among the 107 countries and regions, 65 were low- and middle-income, and 42 were high-income countries and regions, with a total of 405 528 school-going adolescents (mean [SD] age, 14.2 [1.7] years; 196 147 [48.4%] males). The prevalence of overweight and obesity among adolescent students varied from 3.3%(95% CI, 2.6 to 4.1) in Cambodia to 64.0%(95% CI, 57.0 to 71.6) in Niue, and the prevalence of adolescent students consuming soft drinks 1 or more times per day varied from 3.3%(95% CI, 2.9 to 3.7) in Iceland to 79.6%(95% CI, 74.0 to 85.3) in Niue. There was a positive correlation between the prevalence of daily soft drink consumption and the prevalence of overweight and obesity (R, 0.44; P <.001). The pooled analysis using individual-level data also showed a statistically significant association between daily soft drink consumption and overweight and obesity (daily soft drink consumption vs nondaily soft drink consumption), with an odds ratio of 1.14 (95% CI, 1.08 to 1.21) among school-going adolescents. CONCLUSIONS AND RELEVANCE In this study of 107 countries and regions, the prevalence of daily consumption of soft drinks was associated with the prevalence of overweight and obesity among adolescent students. Our results, in conjunction with other evidence, suggest that reducing soft drink consumption should be a priority in combating adolescent overweight and obesity.

Smyth et al. performed a 2-year randomized controlled trial (RCT) examining the impact of 6.5 h of dietary advice to reduce sodium intake on blood pressure and biological markers of cardiovascular (CVD) and renal disease.1Smyth A. Judge C. Kerins C. et al.Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trials.eClinicalMedicine. 2023; 57101856Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar However, there are concerns about their methods for assessing urinary sodium and some statements regarding the feasibility of reducing dietary sodium and the evidence supporting sodium reduction. The criteria used by Smyth et al. (at least 50% predicted creatinine excretion) to assess completeness of the 24 h urine collections is unusual and would have included a large number of incomplete collections as complete (e.g., creatinine excretion of at least 60–69% of expected is only 8–49% sensitive to detect incomplete 24 h urine collections compared to the standard of PABA excretion2John K.A. Cogswell M.E. Campbell N.R. et al.Accuracy and usefulness of select methods for assessing complete collection of 24-hour urine: a systematic review.J Clin Hypertens. 2016; 18: 456-467Crossref Scopus (81) Google Scholar). We are unaware of any relevant validation study using 24 h urine creatinine within 50% of predicted. The method used to assess completeness of 24 h urines can have a more than 2-fold impact on reported sodium excretion.3Wielgosz A. Robinson C. Mao Y. et al.The impact of using different methods to assess completeness of 24-hour urine collection on estimating dietary sodium.J Clin Hypertens. 2016; 18: 581-584Crossref Scopus (37) Google Scholar To allow interpretation of sodium excretion data, Smyth et al. should use a standard method (e.g., creatinine excretion index <0.7 is the most sensitive for removing incomplete collections) and report the rates of incomplete 24 h urines at each time point where they report 24 h urine sodium excretion.2John K.A. Cogswell M.E. Campbell N.R. et al.Accuracy and usefulness of select methods for assessing complete collection of 24-hour urine: a systematic review.J Clin Hypertens. 2016; 18: 456-467Crossref Scopus (81) Google Scholar Smyth et al., do not provide adequate context when stating that “observational studies report conflicting findings on the association of low sodium intake with CVD and mortality, with some studies reporting a higher risk at low intake (<3 g/day) compared to moderate intake”, and that a recent large RCT in patients with heart failure did not report a lower risk of mortality of CVD with low sodium intake.1Smyth A. Judge C. Kerins C. et al.Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trials.eClinicalMedicine. 2023; 57101856Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Smyth et al., also state long term dietary advice studies are ineffective at reducing sodium below 3000 mg/day which contrasts with major trials of dietary advice that lowered sodium intake to less than 3000 mg/day.1Smyth A. Judge C. Kerins C. et al.Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trials.eClinicalMedicine. 2023; 57101856Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar,4Campbell N.R.C. Whelton P.K. Orias M. et al.2022 World hypertension league, resolve to save lives and international society of hypertension dietary sodium (salt) global call to action.J Hum Hypertens. 2022; https://doi.org/10.1038/s41371-022-00690-0Crossref Scopus (10) Google Scholar A meta-analysis of RCTs based on dietary advice had an average reduction in sodium intake from 3646 to 2690 mg/day with a 26% reduction in CVD and a linear association of CVD with sodium intake down to 2300 mg/day.4Campbell N.R.C. Whelton P.K. Orias M. et al.2022 World hypertension league, resolve to save lives and international society of hypertension dietary sodium (salt) global call to action.J Hum Hypertens. 2022; https://doi.org/10.1038/s41371-022-00690-0Crossref Scopus (10) Google Scholar Thus, dietary advice is feasible to lower dietary sodium below 3000 mg/day and reduces CVD. Furthermore, an analysis of cohort studies that used the recommended multiple 24 h urine collections found a linear association of sodium intake from 1846 to 5230 mg/day with CVD.4Campbell N.R.C. Whelton P.K. Orias M. et al.2022 World hypertension league, resolve to save lives and international society of hypertension dietary sodium (salt) global call to action.J Hum Hypertens. 2022; https://doi.org/10.1038/s41371-022-00690-0Crossref Scopus (10) Google Scholar The National Academies of Science, Engineering and Medicine and 75 national and international nongovernmental organizations have stated that low quality research, such as the cohort studies Smyth et al. cited as showing higher CVD with lower sodium intake, are a driver of the controversy regarding the health benefits of reducing dietary sodium and that nongovernmental organizations have also expressed concern that misinformation about dietary sodium is also a driver of controversy.1Smyth A. Judge C. Kerins C. et al.Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trials.eClinicalMedicine. 2023; 57101856Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar,4Campbell N.R.C. Whelton P.K. Orias M. et al.2022 World hypertension league, resolve to save lives and international society of hypertension dietary sodium (salt) global call to action.J Hum Hypertens. 2022; https://doi.org/10.1038/s41371-022-00690-0Crossref Scopus (10) Google Scholar, 5Cappuccio F.P. Campbell N.R.C. He F.J. et al.Sodium and health: old myths, and a controversy based on denial.Curr Nutr Rep. 2022; 11: 172-184Crossref PubMed Scopus (18) Google Scholar, 6Campbell N.R.C. He F.J. Cappuccio F.P. MacGregor G.A. Dietary sodium 'controversy'—issues and potential solutions.Cur Nutr Rep. 2021; 10: 188-199Crossref PubMed Scopus (10) Google Scholar The change in dietary sodium in the large RCT in heart failure, based on dietary advice, that Smyth et al. cited, reduced dietary sodium from 2286 to 1658 mg/day, far lower than Smyth et al. claim is not feasible and the reduction was associated with an improvement in quality of life and NYHA functional class of heart failure (although mortality was not significantly changed).7Ezekowitz J.A. Colin-Ramirez E. Ross H. et al.Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial.Lancet. 2022; 399: 1391-1400Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar The study by Smyth et al. shows that in the current food environment, it is difficult for individuals to sustain lower sodium intake long-term. Thus, upstream interventions, (e.g., mandatory sodium targets for processed foods), are urgently needed and strongly recommended to improve the food system to reduce sodium intake. NRCC wrote the draft which was reviewed and revised by FJH and GAM. All authors accept responsibility for the publication. NRCC reports personal fees from Resolve to Save Lives (RTSL), the Pan American Health Organization, and the World Bank, outside the submitted work; and is an unpaid member of World Action on Salt, Sugar and Health and an unpaid consultant on dietary sodium and hypertension control to numerous governmental and non-governmental organizations. Dr Campbell chaired the International Consortium for Quality Research on Dietary Sodium/Salt (TRUE) which is an unpaid voluntary position. Dr Campbell was on the Medical Advisory Board of Switch Health (2022–2023) and was a one-time reviewer of a joint Novartis Canada Alberta Health Services collaborative project to treat dyslipidemia. All the honoraria from Switch Health and Novartis Canada have been donated to the University of Calgary to support a community cardiovascular disease prevention recognition award. FJH is an unpaid member of Action on Salt, and World Action on Salt, Sugar and Health (WASSH). GAM is the unpaid Chair of Action on Salt, Action on Sugar, WASSH, and Blood Pressure UK. Dietary counselling to reduce moderate sodium intake: effects on cardiovascular and renal biomarkers: primary findings of the COSIP and STICK phase II feasibility randomised controlled trialsAmong individuals with moderate sodium intake, intensive dietary counselling resulted in small short-term reductions in sodium intake and BP, but no significant effect on sodium intake, BP, or cardiorenal biomarkers at two years. Our trial suggests that it may not feasible to reduce sodium sustainably in those with a sodium intake around 3.0 g/day, through an intensive dietary counselling intervention. Full-Text PDF Open AccessResponse to letter by Campbell et al. regarding the results of the COSTICK trialWe thank Cambpell et al. for taking the time to read our trial report1 and pleased to respond to their comments and queries.2 Full-Text PDF Open Access

Objectives: The aim of this study was to assess the changes in salt intake and concomitant changes in blood pressure (BP) and cardiovascular disease (CVD) mortality in England from 2003 to 2018. Methods: National surveys and death registration data were used for the analysis of salt intake as measured by 24-h urinary sodium excretion (449–1069 participants per year), BP (2651–6738 participants per year) and CVD mortality. Results: A decline in salt intake from 9.38 (SD 4.64) to 7.58 (3.41) g/d was observed between 2003 and 2014 ( P < 0.01), followed by an increase to 8.39 (4.13) g/d in 2018 ( P < 0.01). Similar trends in BP and CVD mortality were also observed between 2003 and 2018. SBP/DBP decreased from 125.3 (15.92)/74.48 (11.33) mmHg to 122.57 (14.92)/73.33 (10.75) mmHg between 2003 and 2014 ( P < 0.01), followed by a plateau up to 2018 [122.04 (14.64)/73.84 (10.54) mmHg, P > 0.05]. Likewise, a fall in stroke and ischaemic heart disease mortality rates was observed between 2003 and 2014, from 12.24 and 43.44 cases per 100 000, to 8.19 and 27.23 cases per 100 000 ( P < 0.01), respectively, followed by a plateau afterwards ( P > 0.05). Conclusion: The UK salt reduction programme was initially successful in reducing population salt intake by 19% (from 9.38 g/d in 2003 to 7.58 g/d in 2014). However, in recent years, the programme stalled and thus led to an interruption in the decline of salt intake. BP and CVD mortality reduction was also interrupted when salt reduction stalled. The changes in salt intake may have played an important role in the concomitant changes in BP and CVD mortality. Urgent action is needed to reinvigorate the UK's once world-leading salt reduction programme.

Hogas et al. recently published their perspective on dietary salt in a mini review [...].

Objective:To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers.Design: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.Setting:Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online.Participants: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.Results: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.Conclusions:These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia's out-of-home sectors.

INTRODUCTION:Cancer is the second leading cause of death across the globe with the majority of deaths occurring in low-income and middle-income countries. Evidence has shown that the cancer burden can be substantially reduced by avoiding behavioural risk factors through comprehensive intervention strategies, including workplace health promotion, which has shown to be cost-effective in developed countries while rarely conducted in developing countries. This study aims to explore a feasible and sustainable approach to the prevention and control of cancer in China by developing an evidence-based comprehensive workplace health model equipped with a smartphone application for implementation.METHODS AND ANALYSIS:This study is designed as a stepped-wedge, cluster-randomised controlled trial. We will recruit 15 workplaces from three cities in China. A total of 750 employees will be randomly selected for evaluation that includes five rounds of survey conducted every 6 months. After the second evaluation, workplaces will be randomly allocated to start the intervention sequentially every 6 months in three steps with five workplaces per step. A mobile application 'Healthy Workplace' will be developed to support the intervention. On-line and off-line health-related activities will be carried out among employees. Employers will provide supportive policies, environment and benefits to facilitate the adoption of healthy behaviours. The primary outcome is the change of Healthy Lifestyle Index Score, which consists of five components including smoking, alcohol drinking, physical activity, diet and body mass index.ETHICS AND DISSEMINATION:The study has been approved by Queen Mary University of London Ethics of Research Committee (QMERC22.257) and Chinese Centre for Disease Control and Prevention Institutional Review Board (202210). Written informed consent is required from all participants. Results will be disseminated through presentations, publications and social media.TRIAL REGISTRATION NUMBER:ChiCTR2200058680.

OBJECTIVE:To determine the effects of salt reduction interventions designed for home cooks and family members.DESIGN:Cluster randomised controlled trial.SETTING:Six provinces in northern, central, and southern China from 15 October 2018 to 30 December 2019.PARTICIPANTS:60 communities from six provinces (10 communities from each province) were randomised; each community comprised 26 people (two people from each of 13 families).INTERVENTIONS:Participants in the intervention group received 12 month interventions, including supportive environment building for salt reduction, six education sessions on salt reduction, and salt intake monitoring by seven day weighed record of salt and salty condiments. The control group did not receive any of the interventions.MAIN OUTCOME MEASURE:Difference between the two groups in change in salt intake measured by 24 hour urinary sodium during the 12 month follow-up.RESULTS:1576 participants (775 (49.2%) men; mean age 55.8 (standard deviation 10.8) years) from 788 families (one home cook and one other adult in each family) completed the baseline assessment. After baseline assessment, 30 communities with 786 participants were allocated to the intervention group and 30 communities with 790 participants to the control group. During the trial, 157 (10%) participants were lost to follow-up, and the remaining 706 participants in the intervention group and 713 participants in the control group completed the follow-up assessment. During the 12 month follow-up, the urinary sodium excretion decreased from 4368.7 (standard deviation 1880.3) mg per 24 hours to 3977.0 (1688.8) mg per 24 hours in the intervention group and from 4418.7 (1973.7) mg per 24 hours to 4330.9 (1859.8) mg per 24 hours in the control group. Compared with the control group, adjusted mixed linear model analysis showed that the 24 hour urinary sodium excretion in the intervention group was reduced by 336.8 (95% confidence interval 127.9 to 545.7) mg per 24 hours (P=0.002); the systolic and diastolic blood pressures were reduced by 2.0 (0.4 to 3.5) (P=0.01) and 1.1 (0.1 to 2.0) mm Hg (P=0.03), respectively; and the knowledge, attitude, and behaviours in the intervention group improved significantly.CONCLUSIONS:The community based salt reduction package targeting home cooks and family members was effective in lowering salt intake and blood pressure. This intervention has the potential to be widely applied in China and other countries where home cooking remains a major source of salt intake.TRIAL REGISTRATION:Chinese Clinical Trial Registry ChiCTR1800016804.

Purpose of Review The scientific consensus on which global health organizations base public health policies is that high sodium intake increases blood pressure (BP) in a linear fashion contributing to cardiovascular disease (CVD). A moderate reduction in sodium intake to 2000 mg per day helps ensure that BP remains at a healthy level to reduce the burden of CVD. Recent Findings Yet, since as long ago as 1988, and more recently in eight articles published in the European Heart Journal in 2020 and 2021, some researchers have propagated a myth that reducing sodium does not consistently reduce CVD but rather that lower sodium might increase the risk of CVD. These claims are not well-founded and support some food and beverage industry's vested interests in the use of excessive amounts of salt to preserve food, enhance taste, and increase thirst. Nevertheless, some researchers, often with funding from the food industry, continue to publish such claims without addressing the numerous objections. This article analyzes the eight articles as a case study, summarizes misleading claims, their objections, and it offers possible reasons for such claims. Summary Our study calls upon journal editors to ensure that unfounded claims about sodium intake be rigorously challenged by independent reviewers before publication; to avoid editorial writers who have been co-authors with the subject paper's authors; to require statements of conflict of interest; and to ensure that their pages are used only by those who seek to advance knowledge by engaging in the scientific method and its collegial pursuit. The public interest in the prevention and treatment of disease requires no less.