The Pan American Health Organization (PAHO) supports Member States in efforts to reduce dietary sodium intake in the Region of the Americas and meet the World Health Organization (WHO) global target of a 30% relative reduction in mean population intake of salt/sodium intake by 2025. The reduction of sodium intake through the reduction of sodium content in food products and the setting of target levels for the amount of sodium in food products and meals is one of the WHO “Best Buys” interventions for the prevention of noncommunicable diseases (NCDs).
The updated PAHO targets in processed and ultraprocessed food products in the Region of the Americas were adopted at the Meeting of the PAHO Technical Advisory Group on Cardiovascular Disease Prevention through Population-wide Dietary Salt Reduction in February 2021.
5 reasons to update the PAHO Regional Targets for the
Reduction of Sodium Content in Food Products
1.- It is consistent with the stated goal in the Salt Smart Consortium Consensus Statement to update the PAHO targets in a phase-wise approach, and also is one of the TAG recommendations during Phase 3 of the initiative of the TAG (2016–2018).
2.- Food supply monitoring data show that a large proportion of food products across a wide range of food categories meet the 2015 PAHO targets, yet sodium intakes remain high across the Region.
3.- More countries have established sodium targets for foods and for a broader range of food categories and subcategories, permitting the update of targets and expansion to a broader number of food categories and subcategories.
4.- National-level monitoring of data on the sodium content of foods has been conducted in many countries since 2015, which can be used to establish new targets. Previous targets were based on existing targets from four countries in the Region: Argentina, Brazil, Canada and Chile.
5.- Broader policy initiatives have been developed. PAHO released a PAHO Nutrient Profile Model for use in several policy applications with a maximun limit set for sodium based on WHO guidelines. Additionally, some countries in the Americas have introduced or proposed front-of-package labeling regulations, including thresholds for the sodium content in foods.
PUBLICATIONS
Updated PAHO Regional Sodium Reduction Targets
This publication contains the Updated Targets including an overview of its methodological approaches
Updated PAHO Regional Sodium Reduction Targets: A Tool to Tackle the Burden of Diet-related Noncommunicable Diseases
This advocacy-oriented publication summarizes the need for such targets, why and how they have been updated, and how countries can achieve them.
QUESTIONS AND ANSWERS
The new and revised sodium targets were based on the distribution of sodium content data (mg/100 g1 ) of food products sold in 18 countries across the Region of the Americas between 2013 and 2015.
A 15% and 30% reduction were calculated for 2022 and 2025, respectively, from the measured levels of sodium at the 50th percentile. If the calculated value for 2025 (30% reduction) was below the 25th percentile, the 25th percentile was used as the 2025 target. When the 2025 target was set at the 25th percentile, the 2022 target was set approximately midway between the median and the 25th percentile.
These new targets are set based on a 30% reduction of the 2015 baseline mean levels, meaning that a broad majority of products have already met this target.
For food product categories where this seemed very challenging, adaptations of the target upward to the 25th percentile were made to ensure feasibility.
These targets are based on real data from countries in the Region
The targets have been developed according to actual data on different food product categories and subcategories, which means that there are already existing products in the market meeting them.
The target setting process has been a phase-wise approach that started with the first targets in 2015 on maximum levels established in countries in the Region and continues now with targets for 2022 and 2025.
Evidence suggests that, once salt intake has been reduced gradually, individuals prefer foods with less salt.(3,4)
3. Kloss L, Meyer JD, Graeve L, Vetter W. Sodium intake and its reduction by food reformulation in the European Union – a review. NFS Journal. 2015;1:9−19
4. Teow BH, Nicolantonio RD, Morgan TO. Sodium chloride preference and recognition threshold in normotensive subjects on high and low salt diet. Clin and Expert Hyertens. 1985;7:1681−95
Development of cardiovascular disease (CVD) is influenced by risk factors such as: tobacco use, an unhealthy diet, physical inactivity, obesity (which can result from a combination of unhealthy diet, physical inactivity, and other factors), elevated blood pressure (hypertension), abnormal blood lipids (dyslipidaemia) and elevated blood glucose (diabetes mellitus). Continuing exposure to these risk factors leads to further progression of atherosclerosis, resulting in clinical manifestations of these diseases, including angina pectoris, myocardial infarction, heart failure and stroke. Total CVD risk depends on the individual’s overall risk-factor profile.
• In most developed countries and in an increasing number of developing ones, the major part (70−80%) of dietary salt consumed by the population comes from ultra-processed and processed products or restaurant foods. • Dietary patterns are being transformed by the increasing production and availability of ultra-processed and processed products, rapid urbanization, and changing lifestyles. Reducing the sodium content in the targeted food product categories is also to be complemented with other measures to reduce sodium intake included in the SHAKE package
The essential elements of any successful salt reduction program are comprehensive national salt reduction program in line with the SHAKE package. Awareness campaigns are relevant, but they needed to be accompanied by other effective measures. These include the reduction of sodium content of processed and ultra-processed products, marketing restrictions, front-of-package labeling, and promotion of healthier environments (e.g. schools), among others
Education is an indispensable tool in improving population health and should be fully supported. Reducing the sodium content of food products is a complementary policy option as are front-of-package labeling and marketing restrictions
People worldwide consume significantly more sodium than they should, and the Region of the Americas is no exception. Daily salt consumption ranges from about 8.5 g to 15 g in the Americas (5). The World Health Organization (WHO) recommends a reduction in sodium intake. There is no minimum sodium intake recommendation.
The world and the Region have indigenous populations with no records of salt consumption, and no levels of hypertension. This shows that populations do not need salt, apart from sodium naturally present in foods and have not always had these high levels of salt consumption; but rather, there has been a significant increase in the consumption of processed and ultra-processed products
5. Trieu, K., Neal, B., Hawkes, C., Dunford, E., Campbell, N., Rodriguez-Fernandez, R. et al 2015, Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target. PLoS ONE, 10(7), e0130247. http://doi.org/10.1371/journal.pone.0130247nbsp;
PAHO also presents a new additional and complementary set of targets based on the sodium content per calorie (mg/100 kcal). This approach aligns with the PAHO Nutrient Profile Model, which uses the ratio of mg of sodium/kcal to identify products that are excessive in terms of sodium content when this ratio is equal or higher than one. Some products that might reach their category target may still be excessive in terms of sodium content. Expressing targets in mg/kcal will allow countries to readily identify these products and will also serve as an additional tool for monitoring the presence of products with excessive amounts of sodium
To set these targets, data on the distribution of sodium mg/kcal from five countries were used: Argentina, Canada, Costa Rica, Paraguay, and Peru. To set sodium targets for all new and revised food subcategories based on mg/100 kcal, a 15% and 30% reduction was set for 2022 and 2025, respectively, from the measured levels of sodium at the 50th percentile
The fact that the new targets are based on actual sodium content data from 18 countries in the Region and that many products are produced by multinational companies active in the Region implies that they are feasible, even for countries with no current monitoring data in place.
The fact that the new targets are based on actual sodium content data from 18 countries in the Region and that many products are produced by multinational companies active in the Region implies that they are feasible, even for countries with no current monitoring data in place.
PAHO recommends the targets as “minimum” maximum targets for all countries.
Both the strategies to reduce sodium content in food products and front-of-package labeling policies are complementary and are included into the WHO “Best Buys” for sodium reduction together with strengthening surveillance mechanisms, promoting healthier environments (e.g. schools), restricting marketing of products high in sodium, and implementing awareness-campaigns (e.g. social marketing strategies)
There are certain food products that, even after gradual and progressive sodium content reductions, will still remain excessive in terms of sodium content. Therefore, it is crucial to provide consumers with clear and easy-tounderstand information that warns them about the excessive sodium content of such products.
Regional targets for specific food categories are a guide and a tool for countries to promote and implement their own strategy to reduce sodium content in food products. They can adapt targets to fit their national reality and public health needs. For example, countries with higher levels of sodium content in their food supply can implement more stringent targets for the categories and subcategories they may consider necessary
Launching of the Updated PAHO Regional Sodium Reduction Targets
On 26 October 2021, PAHO hosted a webinar to present the updated Regional Sodium Reduction Targets, aimed to ministries, other governmental entities and decision-makers, researchers, health professionals and civil society organizations. Check the agenda here.
Recording
Recording with the original audio available at https://youtu.be/LVrWhvnpQy0
