The United Kingdom has successfully implemented a salt reduction programme. We carried out a comprehensive analysis of the programme with an aim of providing a step-by-step guide of developing and implementing a national salt reduction strategy, which other countries could follow. The key components include (1) setting up an action group with strong leadership and scientific credibility; (2) determining salt intake by measuring 24-h urinary sodium, identifying the sources of salt by dietary record; (3) setting a target for population salt intake and developing a salt reduction strategy; (4) setting progressively lower salt targets for different categories of food, with a clear time frame for the industry to achieve; (5) working with the industry to reformulate food with less salt; (6) engaging and recruiting of ministerial support and potential threat of regulation by the Department of Health (DH); (7) clear nutritional labelling; (8) consumer awareness campaign; and (9) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, (b) repeated 24-h urinary sodium at 3–5 year intervals. Since the salt reduction programme started in 2003/2004, significant progress has been made as demonstrated by the reductions in salt content in many processed food and a 15% reduction in 24-h urinary sodium over 7 years (from 9.5 to 8.1 g per day, P<0.05). The UK salt reduction programme reduced the population’s salt intake by gradual reformulation on a voluntary basis. Several countries are following the United Kingdom’s lead. The challenge now is to engage other countries with appropriate local modifications. A reduction in salt intake worldwide will result in major public health improvements and cost savings.
Evidence from various types of studies have consistently shown that a high-salt intake increases blood pressure and thereby increases the risk of strokes, heart attacks, heart failure and kidney disease.1, 2, 3, 4 A high-salt intake also has other harmful effects on health, for example, increasing the risk of stomach cancer5 and linked to obesity through an increase in sugar-sweetened soft drink consumption.6 The current salt intake in most countries around the world is ≈9–12 g per day and a reduction in salt intake is considered one of the most cost-effective measures to improve public health.7, 8, 9 As such, many national and international organisations have advocated for a reduction in population salt intake and recommended population-based intake targets, for example, in the United Kingdom, the National Institute for Health and Clinical Excellence recommends <6 g per day by 2015 and a further reduction to 3 g per day by 2025.9 At the 2011 UN high-level meeting on non-communicable diseases, salt reduction was listed as one of the top three priority actions to reduce premature mortality from non-communicable diseases by 25% by 2025.10, 11 The WHO (World Health Organisation), in its recent guideline (January 2013), recommends a 30% reduction by 2025 with an eventual target of 5 g per day worldwide.12 Following on from this, member states at the 66th World Health Assembly (25 May 2013) formally adopted these WHO salt targets as a part of an omnibus resolution to tackle non-communicable diseases.13 The question now is ‘how should countries reduce salt intake in order to meet these targets’?
In 2003, the United Kingdom, through Consensus Action on Salt and Health (CASH), a non-governmental organisation (NGO), and the Food Standards Agency (FSA), a quasi-government organisation, developed a programme of voluntary salt reduction in collaboration with the food industry. This has resulted in a fall in salt intake in the UK population.14, 15 A few recent papers16, 17, 18 have assessed the UK salt reduction policy and each of these papers has a particular focus on different aspects, for example, health economics evaluation,16 the estimated changes in salt intake,17 the leadership and industry aspects.18 We have carried out a comprehensive analysis of the UK salt reduction programme with the aim of providing a simple step-by-step guide of developing, implementing and monitoring a national salt reduction programme that other countries can follow.
The UK salt reduction strategy
We identified a number of key components of the UK salt reduction programme (Figure 1) including (1) setting up an action group with strong leadership and scientific credibility; (2) determining salt intake by measuring 24-h urinary sodium in a random sample of the population and identifying the major sources of salt in the diet by dietary record or recall; (3) setting a target for population salt intake and developing a salt reduction strategy; (4) setting progressively lower voluntary salt targets for different categories of food, with a clear time frame for the food industry to achieve; (5) working with and engaging the food industry to encourage reformulation of food to contain less salt to meet these targets; (6) engaging and recruiting of ministerial support and potential threat of regulation by the DH; (7) introducing clear labelling of salt content in food; (8) conducting consumer awareness campaign; and (9) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, and (b) repeated 24-h urinary sodium at 3–5-year intervals.
Setting up an action group—CASH
In 1994, a review from the government’s advisory committee on medical aspects of food policy to reduce cardiovascular disease recommended a reduction in salt intake to <6 g per day for the UK adult population amongst many other recommendations.19 In 1996, the UK government specifically rejected the recommendations on salt because of pressure from the food industry who threatened to withdraw funding to the political party in power.20, 21, 22 In response, 22 experts on salt and blood pressure (mainly drawn up from the committee on medical aspects of food policy) set up an action group—CASH.
The aims of CASH were, and still remain, (1) to ensure the scientific evidence about the dangers of high-salt consumption becomes translated into policy; (2) to reach a consensus with the food manufacturers and suppliers that there is strong evidence that salt is a major cause of raised blood pressure and has other adverse health effects, and that they need to universally and gradually reduce the large and unnecessary amounts of salt that they add to food; and (3) to educate the public in becoming more salt aware in terms of understanding the impact of salt on their health, checking labels and avoiding products with high salt.
CASH has been very successful in raising awareness of the importance of salt reduction through strong leadership, scientific input and utilising a wide range of advocacy tools including direct lobbying of MPs (Members of Parliament) and food industry via meetings and letters, producing media statements and press releases, carrying out research to enhance knowledge in the field, responding to consultations, collaborating with other stakeholders, holding parliamentary events and organising awareness activities directed to consumers.20
The advocacy work of CASH was instrumental in ensuring that the Chief Medical Officer accepted that a high-salt intake is harmful to health and this resulted in the DH changing its stance on salt and finally endorsing the original recommendations of committee on medical aspects of food policy to reduce salt intake to <6 g per day. By working with several large supermarkets, for example, Asda, Marks & Spencer and Sainsbury’s, CASH was also able to successfully get them on board and to start reducing salt content of their food. In 1999, the FSA was set up primarily to deal with the aftermath of new variant Creutzfeldt-Jakob disease. Again, through lobbying Parliament and, in particular, the public health minister, CASH was able to ensure, with the support of the then public health minister, Tessa Jowell, that the FSA took on the responsibility for salt reduction as part of its nutrition work. The FSA then asked the Scientific Advisory Committee on Nutrition to carry out a review on salt, which confirmed that there was strong evidence to reduce salt intake in the whole population.23 Following this, the FSA and DH made a commitment to work to reduce the salt intake of the UK population.
Initially, CASH had no funds and work was done by research staff who were supported by other grants, putting in extra time. Within a few years CASH was successful in receiving donations. CASH became a charity in 2003 and since then has employed three nutritionists for its work. Approximate expenditure since it was founded in 1996 up to 2011 has been around £1 000 000. In the 3 years leading up to 2011, this was also helped by a grant from the British Heart Foundation for specific projects on reducing salt eaten outside the home.
Determining population salt consumption, identifying sources of salt in the diet and developing a salt reduction strategy
An important step for all countries who want to develop a salt reduction policy is to determine the amount of salt consumed and to identify the major sources of salt in the diet. The most reliable method of estimating dietary salt intake is to measure sodium excretion from 24-h urine collection, a method now endorsed by the WHO.24 Dietary methods such as dietary recall or dietary record are not accurate for determining salt intake but can be used to identify the sources of salt in the diet, which then allows a strategy to be developed, particularly focusing on the biggest sources of salt in the diet, for example, in the United Kingdom, bread, processed meat products and cheese.25
CASH proposed the UK salt reduction strategy (Table 1) in 2003 based on an average salt intake of 9.5 g per day as calculated from 24-h urinary sodium in the National Diet and Nutrition Survey.25 From dietary record data,25 it was estimated that ≈15% of the salt consumed (that is, 1.4 g) was added by consumers either at the table or during cooking, 5% was naturally present in the food (0.5 g) and the rest, ≈80% (7.6 g), was added by the food industry in processed food. In order to reach the target of 6 g, a total reduction of 3.5 g (that is, 40%) was needed. Therefore, the food industry would need to reduce the amount of salt added to all food from 7.6 to 4.6 g (40% reduction) and the public would need to reduce the amount of salt they add to food themselves from 1.4 to 0.9 g (40% reduction). Any failure to reduce salt in a particular food category would mean bigger reductions have to be made in other categories.
Setting targets for different categories of food
From 2004, the FSA with input from CASH and other stakeholders developed a model to look at the effects of reducing the average salt content of different food categories on the population’s salt intake.26 The model provided details for various food categories on the mean level of salt content, the amount of food consumed daily, their contribution to total salt intake and reductions needed in the salt content that would bring the consumption down to the recommended level of 6 g per day. The first set of salt targets were published in March 2006 and devised for the industry to achieve by 2010 (that is, over a 4-year period). They covered 85 categories of processed food that contribute most salt to the diet.27 The aim was to implement a gradual stepwise reduction in salt added to food, for example, 10–20% reduction and repeated at 1–2-year intervals. Such reductions are not detectable by human salt taste receptors28 and cause no safety and very few technical issues to the food in question, therefore posing no risk to sales and no rejection from consumers. Importantly, the food industry demanded a level-playing field so that all companies had to reduce the salt content in that particular food category to the same salt target. These would be closely monitored and independently checked by the FSA, as well as surveys by CASH.
Since the targets were set in 2006, nearly all manufacturers and retailers have made significant reductions in the amount of salt added to food.18 In 2008, the FSA revised the targets from 2010 to 2012 to reflect this progress29 with even lower amounts of salt to be added to processed food. It was envisaged at that time that further targets would be set in 2010, to run from 2012 to 2014, thereby giving the food industry 4 years to achieve. These targets would run progressively until the 6-g per day target for population salt intake is reached.
Engaging with the food industry
In most developed countries, ≈75–80% of salt in the diet is added to food at the stage of manufacturing.30 Therefore, to achieve a reduction in population salt intake, it is vital that the food industry reduces the amount of salt they add to all food. Both CASH and the FSA have been working with all sectors of the food industry to engage, praise, cajole and, if necessary, shame manufactures to ensure they reduce salt and meet the targets. As a result, nearly all food manufacturers, retailers and trade associations, as well as several catering companies have agreed to work towards the targets and started reformulation.
Much of the publicity in the media is designed to influence not only the public but also the management of the food industry as they are very concerned about being ‘named and shamed’ as the company that has the highest salt content of individual food, or is not pulling their weight in the salt reduction policy.
Clear labelling of salt content in food
Clear front of pack labelling of the salt content in food is essential for consumers to choose products with less salt. In the United Kingdom, there are three main types of front of pack nutritional labelling: (1) a traffic light or colour-coding system where there is a colour coding to show the levels of salt, fat, saturated fat and sugar, that is, low (green), medium (amber) and high (red). (2) A guideline daily amount system where the amount per portion is given as a percentage of the adult daily recommended maximum. (3) A hybrid model combining traffic light colours, the words ‘high, medium and low’ and guideline daily amounts. These three main types have been widely used in various ways to label salt, such as salt per 100 g, salt per portion, sodium per 100 g and sodium per portion. If sodium (g) is on the label, then consumers have to multiply sodium by 2.5 to get salt (g). Such different labelling forms have caused confusion for consumers.
Independent research carried out by the FSA has shown that the traffic light labelling is preferred by consumers as they can see at a glance whether a product has a little or a lot of salt.31, 32 Despite this, a significant part of the food industry has not implemented this labelling and, indeed, strongly opposes any legislation on labelling. The European Parliament has also voted against making the traffic light labelling system mandatory in Europe, and the shape of the final nutritional labelling legislation is uncertain.
CASH along with several other NGOs have campaigned for a single front of pack nutrition labelling scheme, which includes traffic light colour coding. In October 2012, the DH announced that a consistent front of pack food labelling (that is, the hybrid labels) will be introduced in the United Kingdom in 2013.33 However, the scheme will still be voluntary.
Consumer awareness campaign
Another key component of the salt reduction programme is consumer awareness. The public should be educated about the dangers of eating too much salt on their health, should be encouraged to reduce the amount of salt they add to food at the table and during cooking and importantly to check product labels choosing lower-salt options.
In the United Kingdom, CASH has used various methods including regular press releases resulting in widespread media coverage, for example, television, radio, press and internet, as well as consumer resources to engage the public.20 In addition, CASH has organised annual National Salt Awareness Week since 2001 to raise awareness of the dangers of a high-salt diet and encourage local events to be held to highlight the importance of salt reduction. The week provides an opportunity for significant media coverage and the local events enable the message of salt reduction to reach those who would be otherwise unaware of it.
Between 2004 and 2007, the FSA launched a three-stage consumer awareness campaign.34 The first stage was to raise awareness that too much salt is bad for health. The second stage alerted adults to the fact that they should be consuming no more than 6 g of salt per day. The final stage focused on the fact that 75% of salt consumed comes from processed food and therefore consumers should check the labels.
Following the FSA’s media campaign, an independent company carried out surveys in a UK representative sample of 2000 adults to evaluate the impact. The results showed that, from 2004 to 2009, the number of people who made an effort to cut down on salt increased by 26% (that is, from 34 to 43%), the number of consumers trying to reduce salt by checking labels increased by 72% (that is, from 29 to 50%), and there was also a 10-fold increase in the awareness of the 6-g per day target.35 However, market research indicated that the FSA’s media campaign was not very effective in the long term, and incurred significant costs. An NGO like CASH could be much more effective and ensure a longer and more continuous media exposure at much less cost.
Progress made in the United Kingdom
Changes in salt content in food
Various sources of data, for example, product surveys, data collected from food companies, have consistently shown reductions in salt content in food. For instance, surveys carried out by the FSA and CASH showed that the average salt level of ready meals on sale in the UK supermarkets reduced by 45% from 2003 to 2007 (that is, from 3.3 to 1.8 g of salt per serving).36
Bread is the single largest contributor of salt to the diet in the United Kingdom, accounting for 18% of total salt intake from food.37 Surveys carried out by CASH and the FSA showed a reduction in salt content of bread by 20% from 2001 to 2011 (Figure 2; with the average level reduced from 1.23 to 0.98 g salt per 100 g bread).38 In the latest CASH survey carried out in 2011,38 144 out of the 203 (71%) products had reached the FSA 2012 salt target for bread (that is, ⩽1.0 g salt per 100 g bread).29
Table 2 illustrates some examples of reductions in salt content for a selection of food categories. The data were collected as a part of CASH’s rolling survey programme, which aimed at monitoring the salt content of processed food sold in the UK supermarkets.39 Data were collected in store from nutrition panels on the product packaging and from company websites. The surveys covered the leading supermarkets—Asda, Sainsbury’s, Tesco, Waitrose, Marks & Spencer and The Co-operative. Among the food groups surveyed, all showed a decrease in salt levels, although there is a variation in the extent of reduction (Table 2).
Consumer salt use
An analysis of the Health Survey for England data showed a steady decline in salt use at the table since 1997, and this reduction was significantly greater after the introduction of the FSA’s salt reduction campaign in 2003. The percentage of adults who add salt at the table decreased from 32.5% in 2003 to 23.2% in 2007.40
Table and cooking salt sales
From 2004 to 2007, table and cooking salt sales in the United Kingdom decreased by ≈20%. Since 2007, more than 11 million kilograms of salt have been removed from food covered by the FSA’s salt reduction targets.41
Changes in mean population salt intake in England
The average salt intake, as measured by 24-h urinary sodium excretion in a random sample of the adult population, was 9.5 g per day in 2000/2001. Salt intake fell to 9.0 g per day in 2005/2006, 8.6 g per day in 2008 and fell further to 8.1 g per day by 2011.15 As 24-h urinary sodium was not measured in 2003/2004 when the UK salt reduction programme started, it is assumed that salt intake was the same as that in 2000/2001. Therefore, from 2003/2004 to 2011, salt intake decreased by 1.4 g per day (that is, 15%, P<0.05 for the downwards trend).15 In other words, there has been a steady fall in salt intake at a rate of ≈2% per year since the introduction of the UK salt reduction strategy. As shown in Table 3, the reduction occurred in both men and women, and in all age groups.
Estimated health and economic impact
Several cost-effective analyses have shown that salt reduction is likely to be very cost-effective.7, 8, 16, 42 In the United Kingdom, an analysis by the National Institute for Health and Clinical Excellence showed that the UK salt reduction campaigns cost ≈£15 million and the 0.9-g per day reduction in salt intake achieved by 2008 led to ≈6000 fewer CVD deaths per year, saving the UK economy ≈£1.5 billion per annum.9, 43 On the basis of the estimation of the National Institute for Health and Clinical Excellence, the further reduction of 0.5 g per day achieved by 2011 would prevent ≈3000 additional CVD deaths amounting to a total of ≈9000 fewer CVD deaths per year. Further, there would also be ≈9000 non-fatal CVD events prevented per year and greater cost savings to the UK economy.
The UK salt reduction—challenges ahead
Continuing efforts and new targets are urgently needed
Despite considerable reductions in salt content being made in many processed food and the resulting downward trend in salt consumption, the mean population salt intake of 8.1 g per day is still 35% higher than the recommended level of 6 g per day, and 70% of the adult population (80% men and 58% women) had a daily salt intake above the recommended level.15 With the current rate of 2% reduction per year, it would take another 12 years for the population salt intake to reach the target of 6 g per day. Therefore, continuing and greater efforts are needed, in particular, lower salt targets should be devised urgently. Taking bread as an example, by 2011, 71% of bread products had already met the FSA’s 2012 targets (that is, ⩽1.0 g salt per 100 g bread).29 Therefore, the target should now be revised down to <0.9 g per 100 g for the industry to achieve by 2014/2015. This is a realistic target in view of the fact that 27% of the bread products surveyed in 2011 had salt levels already at or below this level. In March 2013, the DH announced its plan to revise the salt targets for various categories of food by the end of the year.44
The transfer of salt reduction from the FSA to the DH in England
The FSA has had an important role in the implementation of the salt reduction policy, particularly as they were independent and free of political control. At the same time, they had considerable power over the food industry in relation to food safety, making a voluntary policy likely to be successful. Without this and a forceful NGO, the salt reduction policy may not have been so successful. However, in October 2010, the DH directed by the Secretary of State for Health took responsibility for nutrition from the FSA. In March 2011, salt reduction was announced as one of the public health goals to be included in a new initiative called the ‘Public Health Responsibility Deal’,45 which aims to bring together public sector, academic, commercial and voluntary organisations. The Responsibility Deal salt pledge adopted the FSA salt targets for 2012 but made the industry responsible! The FSA had planned to introduce a new set of targets in 2010 (to be met by 2014) but the DH failed to commit to plans for new targets until early 2013. This has meant a loss of momentum (3 years) in the salt reduction programme.
Further, the FSA’s strategy provided an independent and transparent monitoring programme to assess progress made towards the targets, whereas the Responsibility Deal allows companies to use their own monitoring format making it extremely difficult to compare companies. Strong independent and transparent monitoring, however, is vital in order to make a voluntary policy successful.
The DH should enhance the FSA’s strategy with the introduction of substantial disincentives for non-participation and sanctions for non-compliance,46 as well as a robust independent monitoring system. If the food industry refuses to comply, then regulation/legislation of the salt targets must be implemented.
Technical feasibility and consumer acceptance
Technical feasibility and consumers’ taste acceptance of lower-salt food have been claimed as reasons for the lack of progress in reducing salt in food by some sections of the food industry. However, the wide range of salt levels seen in similar range of food that are already on the market (Table 2), many of which are below the target, demonstrate that, technically, it is feasible to reduce salt levels further in almost all processed food.
Salt is a very poor preservative requiring a 15% concentration in the aqueous phase to inhibit bacterial growth and is now rarely used as a preservative as other chemicals are more effective. Salt is used in combination with polyphosphate to bind water to meat and fish products increasing the weight at very little cost, but other chemicals can now be used to increase water content if this is really felt to be necessary by the food industry. In relation to taste, as salt intake falls, the salt taste receptors in the mouth adapt and become more sensitive within 4–6 weeks. This means that lower concentrations of salt then taste as salty as the previous higher concentrations, provided salt reduction is made by slow graded amounts by the entire food industry. Indeed, well-controlled studies have shown that once salt intake is reduced, individuals prefer food with less salt.47 The UK experience indicates that, when the salt content in food is gradually reduced, there have been very few complaints about the taste and no decrease in sales.
The catering sector
The UK salt reduction programme has predominantly focused on food sold in supermarkets, and the catering sector is lagging behind. Most of the out-of-home food contain a disproportionately high amount of salt. For instance, CASH carried out a survey in 2012 on pepperoni and margherita pizzas from takeaway outlets in 17 London Boroughs and 8 supermarkets.39 There were 81 types of pizza from takeaways and 118 from supermarkets. The results showed that takeaway pizzas contained 45% more salt than the equivalent supermarket pizzas (1.57 vs 1.08 g salt per 100 g pizza, P<0.001) and, shockingly, a margherita pizza from Pizza Express restaurant contained almost double the amount of salt compared with its equivalent in the supermarket (1.49 vs 0.85 g per 100g).39
In view of the fact that more and more people are eating out and the catering sector (that is, restaurants, takeaways, fast food outlets, caterers, canteens, prisons and hospitals) now provides one in six (15%) meals,48 there is an urgent need for this part of the food industry to get on board with salt reduction. In July 2012, the DH added three new salt pledges to the Responsibility Deal,45 with special focus on the catering sector.49 These pledges focus on training and kitchen practice, reformulation and procurement. The pledges commit companies to a 15% reduction in salt used in their kitchens, ensuring at least 50% of the products they procure meet the 2012 targets within 1 year of sign up and increasing further over time and/or reformulating the dishes with less salt. Immediately after the launch, 15 companies have signed up to at least one of these pledges.49 It is vital that the new salt targets that are to be set in 2013 also apply to food eaten outside home as similar food in the supermarkets ensuring a level-playing field.
Salt intake in Scotland
The 24-h urinary sodium data collected in 2006 suggested that salt intake was higher in Scotland and lower in Wales compared with that in England.15 A repeated measurement of 24-h urinary sodium in Scottish population in 2009 showed little reduction in salt consumption.15 As the UK salt reduction strategy has been implemented in all UK countries, it is difficult to explain this difference between countries. It is possible that this may be partially due to a difference in socio-economic status or the Scottish people may be eating out more often. Given the high prevalence of hypertension and cardiovascular disease in Scotland, much greater input is needed from the devolved Scottish government. It should be noted that Scotland is leading the work in public health policies in the United Kingdom on tobacco and alcohol, and is soon to launch its own independent agency (that is, Scottish FSA) to focus on nutrition, food labelling and food safety.50 It is possible that Scotland could take the lead on salt reduction in the future.
Lessons learned and an international perspective
The UK salt reduction strategy—a model for other countries
One of the key factors contributing to the United Kingdom’s success on salt reduction is setting progressively lower salt targets, coupled with a forceful government or quasi-government agency and NGOs to ensure all companies are aware of the targets and make reductions to achieve the same low salt levels. It is also essential to have a monitoring strategy in place; for example, repeated surveys of food products and 24-h urinary sodium. An important lesson learned from the UK programme is the need for clear guidelines and targets for the catering sector as well as the retail sector.
The UK salt reduction model could be used as a template by most developed countries where the majority of salt in the diet is from processed food. Indeed, several countries, for example, the United States, Canada and Australia are already adopting the United Kingdom’s model and setting their own voluntary targets for salt levels in processed food. Recently, South Africa has taken a regulatory approach to target setting and has done so with the tacit support of the food industry to further ensure a ‘level-playing field’.
Multinational companies—a global policy
Salt reduction has been incorporated into many companies’ policies for the UK food market. These policies also ensure that new products follow the salt targets. Multinational companies must now apply a global policy to reduce the salt content of their products to the lowest level in all countries where they are marketed. At the moment, there is a very large variation in the amount of salt added to the same branded products in different countries.51, 52 For example, a survey conducted by the World Action on Salt & Health—founded in 2005 based on the success of CASH, including over 260 branded products from KFC, McDonalds, Kellogg’s, Nestle, Burger King and Subway in different countries,51 showed that every product had a different salt content in different countries and no one single product surveyed had the same salt level around the world, with some showing large variations. For instance, Kellogg’s All Bran contained 2.15 g of salt per 100 g in Canada but only 0.65 g of salt per 100 g just over the border in the United States, less than one-third of the Canadian level.51 This illustrates once again how easy it would be for the food industry to reduce the amount of salt they add to food, particularly, as they could do this straightaway to their branded products. Pressure resulting from surveys such as this has led to several large multinational manufacturers pledging to reduce the amount of salt added to food across the world. Those already committed to salt reduction worldwide include Pepsico, Unilever, Kellogg’s, Heinz, Campbell’s and Kraft, but how far they have put this pledge into action is not clear. On the other hand, some international companies have exported their reduced salt products manufactured for the United Kingdom to other European markets without those countries being aware of the reduction in salt content.
Voluntary vs regulatory/legislative approach
The UK salt reduction programme has been carried out on a voluntary basis, but this has been underpinned by sustained media pressure, direct pressure on the government and ministers, particularly the public health ministers, so that they would maintain a strong stance with the food industry. Regulatory/legislative approaches are likely to be more effective than voluntary approaches. For example, in Denmark, the move from voluntary agreements on trans-fatty acid reduction to the successful implementation of a legislative ban of trans-fatty acid has led to rapid and large reductions in the trans-fatty acid content in processed food and margarines.53 However, in many countries, the process of legislation is very complicated and this may lead to severe delays in action as demonstrated by the pace of tobacco legislation (banning smoking in all workplaces) coming into force.54
Countries therefore need to consider their own political processes to determine whether a regulatory/legislative or voluntary approach is more appropriate. The best way to proceed is to start with a voluntary salt reduction policy with the threat of regulation/legislation and, at the same time, enact the legislation process.
The UK salt reduction programme has led to a 15% reduction in the average salt intake of the population during the past 7 years at a small cost with potentially major health-care savings and potential large reductions in the number of people suffering or dying from strokes, heart attacks and heart failure. Indeed, the United Kingdom now has the lowest known salt intake of any developed country as measured by 24-h urinary sodium.55 A key to success is the rigorous setting of progressively lower salt targets with a clear time frame and independent monitoring programme. Many countries including the United States, Canada and Australia are following the United Kingdom’s lead and setting their own targets. The major challenge now is to spread this out to all other countries. The World Action on Salt & Health, a similar group to CASH with over 500 members in 98 countries, is encouraging action groups to be formed in each country. All countries should adopt a coherent and workable strategy to reduce salt intake. In view of the enormous benefits of salt reduction on public health, it would be negligent for any government not to take action now.
He FJ, Li J, Macgregor GA . Effect of longer term modest salt reduction on blood pressure: cochrane systematic review and meta-analysis of randomised trials. BMJ 2013; 346: f1325.
He FJ, MacGregor GA . Reducing population salt intake worldwide: from evidence to implementation. Prog Cardiovasc Dis 2010; 52: 363–382.
Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl JJ . Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ 2013; 346: f1326.
He FJ, MacGregor GA . Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet 2011; 378: 380–382.
D'Elia L, Rossi G, Ippolito R, Cappuccio FP, Strazzullo P . Habitual salt intake and risk of gastric cancer: a meta-analysis of prospective studies. Clin Nutr 2012; 31: 489–498.
He FJ, Marrero NM, MacGregor GA . Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 2008; 51: 629–634.
Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R . Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370: 2044–2053.
Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ et al. Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 2010; 362: 590–599.
National Institute for Health and Clinical Excellence (NICE). Guidance on the prevention of cardiovascular disease at the population level http://www.guidance.nice.org.uk/PH25, accessed 2013.
First global ministerial conference on healthy lifestyles and noncommunicable disease control, 28–29 April 2011, Moscow http://www.who.int/nmh/events/moscow_ncds_2011/en/, accessed 10 June 2013.
Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P et al. Priority actions for the non-communicable disease crisis. Lancet 2011; 377: 1438–1447.
WHO issues new guidance on dietary salt and potassium, 31 January 2013 http://www.who.int/mediacentre/news/notes/2013/salt_potassium_20130131/en/, accessed 10 May 2013.
Sixty-sixth World Health Assembly, Follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. 25 May 2013 http://www.ncdalliance.org/sites/default/files/rfiles/A66_WHA%20Final%20Resolution.pdf, accessed 29 May 2013.
Food Standards Agency. Dietary sodium levels surveys, 22 July 2008 http://www.food.gov.uk/multimedia/pdfs/08sodiumreport.pdf, accessed 10 June 2013.
Department of Health: Assessment of Dietary Sodium Levels Among Adults (aged 19–64) in England, 2011 http://transparency.dh.gov.uk/2012/06/21/sodium-levels-among-adults/, accessed 25 June 2012.
Shankar B, Brambila-Macias J, Traill B, Mazzocchi M, Capacci S . An evaluation of the UK Food Standards Agency’s salt campaign. Health Econ 2013; 22: 243–250.
Millett C, Laverty AA, Stylianou N, Bibbins-Domingo K, Pape UJ . Impacts of a national strategy to reduce population salt intake in England: serial cross sectional study. PLoS One 2012; 7: e29836.
Wyness LA, Butriss JL, Stanner SA . Reducing the population's sodium intake: the UK Food Standards Agency's salt reduction programme. Public Health Nutr 2012; 15: 254–261.
Cardiovascular Review Group Committee. Report of the Cardiovascular Review Group Committee on Medical Aspects of Food Policy, Nutritional Aspects of Cardiovascular Disease. HMSO: London, UK, 1994.
Consensus Action on Salt and Health http://www.actiononsalt.org.uk/, access verified 23 July 2012.
MacGregor GA, Sever PS . Salt–overwhelming evidence but still no action: can a consensus be reached with the food industry? CASH (Consensus Action on Salt and Hypertension). BMJ 1996; 312: 1287–1289.
Godlee F . The food industry fights for salt. BMJ 1996; 312: 1239–1240.
Scientific Advisory Committee on Nutrition, Salt and health. 2003. The Stationery Office http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf, accessed 5 June 2013.
World Health Organization. Strategies to monitor and evaluate population sodium consumption and sources of sodium in the diet. 2010. http://www.who.int/dietphysicalactivity/reducingsalt/en/index.html, accessed 29 May 2013.
Henderson L, Irving K, Gregory J, Bates CJ, Prentice A, Perks J et al National Diet & Nutrition Survey: Adults aged 19 to 64 2003 3: pp 127–136 TSO: London, UK.
Effects of reducing salt in processed food on the population's salt intake - the salt model http://www.collections.europarchive.org/tna/20100927130941/; http://food.gov.uk/healthiereating/salt/saltmodel February 2005 (accessed 7 June 2012).
Salt reduction targets: March 2006. London, UK: Food Standards Agency, 2006. Available at http://www.food.gov.uk/multimedia/pdfs/salttargetsapril06.pdf, accessed 17 August 2012.
Girgis S, Neal B, Prescott J, Prendergast J, Dumbrell S, Turner C et al. A one-quarter reduction in the salt content of bread can be made without detection. Eur J Clin Nutr 2003; 57: 616–620.
Department of Health. Targets https://www.responsibilitydeal.dh.gov.uk/wp-content/uploads/2012/01/Salt-Targets-for-Responsibility-Deal.pdf, accessed 10 June 2013.
James WP, Ralph A, Sanchez-Castillo CP . The dominance of salt in manufactured food in the sodium intake of affluent societies. Lancet 1987; 1: 426–429.
Food Standards Agency. Traffic light labelling, Signposting http://www.food.gov.uk/foodlabelling/signposting/, accessed 10 June 2013.
Citizens’ forums on food: Front of Pack (FoP) Nutrition Labelling http://www.food.gov.uk/multimedia/pdfs/citforumfop.pdf, access 10 June 2013.
Department of Health, Single system for nutrition labelling announced, 24 October 2012 https://www.gov.uk/government/news/single-system-for-nutrition-labelling-announced, accessed 29 May 2013.
Food Standards Agency health campaign to reduce salt levels and save lives http://www.food.gov.uk/news/pressreleases/2004/sep/saltcampaignpress, accessed 10 June 2013.
Food Standards Agency—UK salt reduction initiatives http://www.food.gov.uk/multimedia/pdfs/saltreductioninitiatives.pdf, accessed 10 June 2013.
Salt in UK ready meals 45% lower than four years ago, Consensus Action on Salt and Health (CASH), 23rd November 2007 http://www.actiononsalt.org.uk/news/surveys/2007/ready/index.html, accessed 17 July 2012.
National Diet and Nutrition Survey: Headline results from Years 1 and 2 (combined) of the rolling programme 2008/9–2009/10 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_128166, accessed 16 August 2012.
Brinsden HC, He FJ, Jenner KH, MacGregor GA . Surveys of the salt content in UK bread: progress made and further reductions possible. BMJ Open 2013; 3: e002936.
CASH Surveys. Consensus Action on Salt and Health http://www.actiononsalt.org.uk/news/surveys/2007/ready/index.html, accessed 17 May 2013.
Sutherland J, Edwards P, Shankar B, Dangour AD . Fewer adults add salt at the table after initiation of a national salt campaign in the UK: a repeated cross-sectional analysis. Br J Nutr 2013; 110: 552–558.
Department of Health: Salt strategy beyond 2012 https://www.responsibilitydeal.dh.gov.uk/wp-content/uploads/2013/03/Salt-Strategy-Beyond-2012.pdf, accessed 17 May 2013.
Barton P, Andronis L, Briggs A, McPherson K, Capewell S . Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ 2011; 343: d4044.
Ofcom, Office of Communications. Impact assessment http://www.stakeholders.ofcom.org.uk/binaries/consultations/foodads_new/ia.pdf, access verified 13 July 2010.
Department of Health. New salt strategy to drive further progress to cut salt https://www.responsibilitydeal.dh.gov.uk/salt-strategy/, accessed 12 May 2013.
Department of Health, Responsibility Deal - http://www.dh.gov.uk/en/Publichealth/Publichealthresponsibilitydeal/index.htm, accessed 10 June 2013.
Bryden A, Petticrew M, Mays N, Eastmure E, Knai C . Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy 2013; 110: 186–197.
Blais CA, Pangborn RM, Borhani NO, Ferrell MF, Prineas RJ, Laing B . Effect of dietary sodium restriction on taste responses to sodium chloride: a longitudinal study. Am J Clin Nutr 1986; 44: 232–243.
Food Service and Eating Out: An Economic Survey. Surveys, Statistics and Food Economics Division, January 2007 http://www.archive.defra.gov.uk/evidence/economics/foodfarm/reports/documents/Food%20service%20paper%20Jan%202007.pdf, accessed 24 July 2012.
Department of Health Responsibility Deal, 27 July 2012 http://www.responsibilitydeal.dh.gov.uk/2012/07/27/good-progress-on-salt-reduction/, accessed 27 July 2012.
Statement on Scottish Government announcement on Food Standards Agency, 27 June 2012 http://www.food.gov.uk/news-updates/news/2012/jun/scotgov, accessed 27 July 2012.
World Action on Salt and Health. Press release - Medical experts launch global campaign against salt to prevent over 2.5 million deaths worldwide each year http://www.worldactiononsalt.com/media/Media_coverage/Archive_Wash_Launch.htm, access verified May 28 2010.
Dunford E, Webster J, Woodward M, Czernichow S, Yuan WL, Jenner K et al. The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction. CMAJ 2012; 184: 1023–1028.
Bech-Larsen T, Aschemann-Witzel JA . Macromarketing perspective on food safety regulation: the Danish ban on trans-fatty acids. J Macromarketing 2012; 32: 208–219.
Brownell KD, Warner KE . The perils of ignoring history: big tobacco played dirty and millions died. How similar is Big Food? Milbank Q 2009; 87: 259–294.
Webster JL, Dunford EK, Hawkes C, Neal BC . Salt reduction initiatives around the world. J Hypertens 2011; 29: 1043–1050.
FJH is a member of Consensus Action on Salt & Health (CASH) and World Action on Salt & Health (WASH). Both CASH and WASH are non-profit charitable organisations and FJH does not receive any financial support from CASH or WASH. GAM is Chairman of Blood Pressure UK (BPUK), Chairman of CASH and Chairman of WASH. BPUK, CASH and WASH are non-profit charitable organisations. GAM does not receive any financial support from any of these organisations. HCB was an employee of CASH while working on the manuscript.
About this article
Cite this article
He, F., Brinsden, H. & MacGregor, G. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 28, 345–352 (2014). https://doi.org/10.1038/jhh.2013.105
- salt reduction
- UK programme
- public health
Nutrition Reviews (2021)
App-Based Salt Reduction Intervention in School Children and Their Families (AppSalt) in China: Protocol for a Mixed Methods Process Evaluation
JMIR Research Protocols (2021)
Estimating the potential impact of Australia’s reformulation programme on households’ sodium purchases
BMJ Nutrition, Prevention & Health (2021)
What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence
Obesity Reviews (2021)