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Salt intakes around the world: implications for public health
Abstract
BACKGROUND: High levels of dietary sodium (consumed as common salt, sodium chloride) are associated with raised blood pressure and adverse cardiovascular health. Despite this, public health efforts to reduce sodium consumption remain limited to a few countries. Comprehensive, contemporaneous sodium intake data from around the world are needed to inform national/international public health initiatives to reduce sodium consumption. METHODS: Use of standardized 24-h sodium excretion estimates for adults from the international INTERSALT (1985-87) and INTERMAP (1996-99) studies, and recent dietary and urinary sodium data from observational or interventional studies--identified by a comprehensive search of peer-reviewed and 'grey' literature--presented separately for adults and children. Review of methods for the estimation of sodium intake/excretion. Main food sources of sodium are presented for several Asian, European and Northern American countries, including previously unpublished INTERMAP data. RESULTS: Sodium intakes around the world are well in excess of physiological need (i.e. 10-20 mmol/day). Most adult populations have mean sodium intakes >100 mmol/day, and for many (particularly the Asian countries) mean intakes are >200 mmol/day. Possible exceptions include estimates from Cameroon, Ghana, Samoa, Spain, Taiwan, Tanzania, Uganda and Venezuela, though methodologies were sub-optimal and samples were not nationally representative. Sodium intakes were commonly >100 mmol/day in children over 5 years old, and increased with age. In European and Northern American countries, sodium intake is dominated by sodium added in manufactured foods ( approximately 75% of intake). Cereals and baked goods were the single largest contributor to dietary sodium intake in UK and US adults. In Japan and China, salt added at home (in cooking and at the table) and soy sauce were the largest sources. CONCLUSIONS: Unfavourably high sodium intakes remain prevalent around the world. Sources of dietary sodium vary largely worldwide. If policies for salt reduction at the population level are to be effective, policy development and implementation needs to target the main source of dietary sodium in the various populations.
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“In Asian countries, most sodium is from soy sauce or is added at home.158”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [158]
In the citing paper
“In North America and Europe, 75% of sodium intake is derived from packaged, preprepared, or restaurant foods, with the rest being naturally occurring or added at home.158”
From Components of a Cardioprotective Diet: New Insights (2011) · cites this paper as [158]
In the citing paper
“In North America and Europe, most sodium (~75%) comes from packaged foods and restaurants, and little from home cooking or table salt; while in Asian countries, most sodium comes from soy sauce and salt added during cooking or at the table.302”
From Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review (2016) · cites this paper as [302]
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“to 75% of dietary sodium, predominantly via sodium chloride (hereafter, referred to as salt or NaCl), followed by a much lesser proportion from discretionary salt use or that which is naturally occurring (Brown et al., 2009).”
BackgroundRole of salt intake in prevention of cardiovascular disease: controversies and challenges
He, F. J., & MacGregor, G. A. (2018) · Nature Reviews Cardiology · doi:10.1038/s41569-018-0004-1 · Cited by 157
Salt intakes in sub-Saharan Africa: a systematic review and meta-regression
Oyebode, O. O., Oti, S. O., Chen, Y., & Lilford, R. J. (2016) · Population Health Metrics · doi:10.1186/s12963-015-0068-7 · Cited by 153
“Brown and colleagues [16] did not find any estimates for African children, while Powles and colleagues [15] did not include children in their systematic review.”
BackgroundResultInfluentialPlant-based diets: a review of the definitions and nutritional role in the adult diet
Kent, G., Kehoe, L., Flynn, A., & Walton, J. (2021) · Proceedings of The Nutrition Society · doi:10.1017/s0029665121003839 · Cited by 162
“This is not unexpected as it is widely reported that sodium intake worldwide is well in excess of recommendations((96)).”
van Lee, L., Geelen, A., van Huysduynen, E. J. C. H., de Vries, J. H. M., Veer, P. V., & Feskens, E. J. M. (2012) · Nutrition Journal · doi:10.1186/1475-2891-11-49 · Cited by 151
“Preferably, sodium intake is measured in 24-hour urine samples, which is considered the standard for measuring sodium intake [37].”
BackgroundNutrition in cardiovascular disease: salt in hypertension and heart failure
He, F. J., Burnier, M., & MacGregor, G. A. (2011) · European Heart Journal · doi:10.1093/eurheartj/ehr194 · Cited by 153
“The current salt intake in many countries is between 9 and 12 g/day.(2) This large increase in salt intake is relatively recent in evolutionary terms.”
BackgroundEnvironmental factors in autoimmune diseases and their role in multiple sclerosis
Haase, S., Grohme, D. A., Erzler, M., Binsfeld, M., Haghikia, A., Müller, D. N., Linker, R. A., & Kleinewietfeld, M. (2016) · Cellular and Molecular Life Sciences · doi:10.1007/s00018-016-2311-1 · Cited by 156
“In particular, processed or so-called ‘fast foods’ may contain significantly more NaCl than homemade meals [145].”
BackgroundMohamed, S. F., Mutua, M. K., Wamai, R. G., Wekesah, F. M., Haregu, T., Juma, P. A., Nyanjau, L., Kyobutungi, C. K., & Ogola, E. N. (2018) · BMC Public Health · doi:10.1186/s12889-018-6052-y · Cited by 149
Use of Urine Biomarkers to Assess Sodium Intake: Challenges and Opportunities
Cogswell, M. E., Maalouf, J., Elliott, P., Loria, C. M., Patel, S., & Bowman, B. A. (2015) · Annual Review of Nutrition · doi:10.1146/annurev-nutr-071714-034322 · Cited by 145
“The types of urine biomarkers (e.g., 24 h-urine sodium excretion) used in surveys and studies to assess sodium intake are often noted in systematic reviews of population sodium intake and the associations between sodium intake and health outcomes (2, 14, 24, 67, 120).”
Self-citationFactors Associated with Medication Nonadherence among Hypertensives in Ghana and Nigeria
Boima, V., Ademola, A. D., Odusola, A. O., Agyekum, F., Nwafor, C. E., Cole, H. V. S., Salako, B. L., Ogedegbe, G. G., & Tayo, B. O. (2015) · International Journal of Hypertension · doi:10.1155/2015/205716 · Cited by 142
“Optimal blood pressure (BP) control with levels below 140/90mmHg is associated with significant reduction in cardiovascular complications such as stroke and coronary heart disease [12, 13].”
Effects of health labels on expected and actual taste perception of soup
Liem, D. G., Aydin, N. T., & Zandstra, E. H. (2012) · Food Quality and Preference · doi:10.1016/j.foodqual.2012.02.015 · Cited by 146
Antonini, S., Arias, M. A., Eichert, T., & Clemens, J. (2012) · Chemosphere · doi:10.1016/j.chemosphere.2012.07.026 · Cited by 137
“Higher values of urinary sodium secretion may be reflected by the dietary practice in Asian countries of using soy sauce as seasoning (Brown et al., 2009).”
MethodCampbell, N. R. C., He, F. J., Tan, M., Cappuccio, F. P., Neal, B. C., Woodward, M., Cogswell, M. E., McLean, R. M., Arcand, J., MacGregor, G. A., et al. (2019) · Journal of Clinical Hypertension · doi:10.1111/jch.13551 · Cited by 136
Tan, M., He, F. J., Wang, C., & MacGregor, G. A. (2019) · Journal of the American Heart Association · doi:10.1161/jaha.119.012923 · Cited by 139
“12,15 In contrast, potassium intake levels were less than half the recommended minimum intake for each age group.”
Anta, R. M. O., López-Sobaler, A. M., Ballesteros, J., Pérez‐Farinós, N., Rodríguez‐Rodríguez, E., Aparicio, A., Perea, J. M., & Andrés, P. (2010) · British Journal Of Nutrition · doi:10.1017/s000711451000423x · Cited by 135
Endothelial function is impaired after a high-salt meal in healthy subjects
Dickinson, K. M., Clifton, P. M., & Keogh, J. B. (2011) · American Journal of Clinical Nutrition · doi:10.3945/ajcn.110.006155 · Cited by 134
Salt reduction: Moving from consumer awareness to action
Zandstra, E. H., Lion, R., & Newson, R. S. (2015) · Food Quality and Preference · doi:10.1016/j.foodqual.2015.03.005 · Cited by 129
WASH—World Action on Salt and Health
He, F. J., Jenner, K. H., & MacGregor, G. A. (2010) · Kidney International · doi:10.1038/ki.2010.280 · Cited by 131
Salt intake and cardiovascular disease: why are the data inconsistent?
O'Donnell, M. J., Mente, A., Smyth, A., & Yusuf, S. (2012) · European Heart Journal · doi:10.1093/eurheartj/ehs409 · Cited by 125
“There are two main approaches to estimate sodium intake, namely measuring urinary excretion or dietary intake.(19) For either method, it is optimal to complete repeated measurements to capture ‘usual’ intake of sodium.”
BackgroundMethodThe role of sodium in modulating immune cell function
Wilck, N., Balogh, A., Markó, L., Bartolomaeus, H., & Müller, D. N. (2019) · Nature Reviews Nephrology · doi:10.1038/s41581-019-0167-y · Cited by 129
Current status of salt reduction in bread and bakery products – A review
Silow, C., Axel, C., Zannini, E., & Arendt, E. K. (2016) · Journal of Cereal Science · doi:10.1016/j.jcs.2016.10.010 · Cited by 132
Ghawi, S. K., Rowland, I. R., & Methven, L. (2014) · Appetite · doi:10.1016/j.appet.2014.05.029 · Cited by 125
Microplastics in Salt of Tuticorin, Southeast Coast of India
Sathish, N., Jeyasanta, K. I., & Patterson, J. (2020) · Archives of Environmental Contamination and Toxicology · doi:10.1007/s00244-020-00731-0 · Cited by 115
Jia, Y. P., Niu, C.-T., Lu, Z., Zhang, X.-J., Chai, L., Shi, J., Xu, Z., & Li, Q. (2020) · Applied and Environmental Microbiology · doi:10.1128/aem.00306-20 · Cited by 121
“to increased risk of hypertension, cardiovascular mortality (3), and obesity (4), and so it”
BackgroundLand, M., Webster, J. L., Christoforou, A., Praveen, D., Jeffery, P., Chalmers, J. P., Smith, W. T., Woodward, M., Barzi, F., Nowson, C. A., et al. (2014) · BMJ Open · doi:10.1136/bmjopen-2013-003720 · Cited by 115
“17 With centrally managed salt reduction programmes projected to deliver large population health gains at very low cost, 18 – 20 the implementation of an effective salt reduction programme should be a priority for the government of Australia.”
BackgroundCampmans-Kuijpers, M. J. E., & Dijkstra, G. D. H. (2021) · Nutrients · doi:10.3390/nu13041067 · Cited by 124
“Surprisingly, countries like China with the highest salt intakes, have lower rates of IBD compared to the Western countries [238,239].”
BackgroundEstimativa de consumo de sódio pela população brasileira, 2008-2009
Sarno, F., Claro, R. M., Levy, R. B., Bandoni, D. H., & Monteiro, C. A. (2013) · Revista de Saúde Pública · doi:10.1590/s0034-8910.2013047004418 · Cited by 112
“575 Rev Saúde Pública 2013;47(3):571-8”
BackgroundInfluentialEvaluation of a screener to assess diet quality in the Netherlands
van Lee, L., Feskens, E. J. M., Meijboom, S., van Huysduynen, E. J. C. H., Veer, P. V., de Vries, J. H. M., & Geelen, A. (2015) · British Journal Of Nutrition · doi:10.1017/s0007114515004705 · Cited by 109
“Urinary Na level was measured using an ion-selective electrode from a Roche/Hitachi 917 analyser (Roche)((22)) at SHO in Velp, the Netherlands.”
MethodA salty‐congruent odor enhances saltiness: Functional magnetic resonance imaging study
Seo, H., Iannilli, E., Hummel, C., Okazaki, Y., Buschhüter, D., Gerber, J. C., Krammer, G. E., van Lengerich, B., & Hummel, T. R. (2011) · Human Brain Mapping · doi:10.1002/hbm.21414 · Cited by 112
“Nevertheless, the average amount of salt intake indeed exceeds the recommended daily intakes in children as well as in adults of worldwide population [Brown et al., 2009].”
BackgroundDietary Salt Intake and Risk of Gastric Cancer
D’Elia, L., Galletti, F., & Strazzullo, P. (2013) · Cancer treatment and research · doi:10.1007/978-3-642-38007-5_6 · Cited by 109
Bolhuis, D. P., Temme, E. H. M., Koeman, F. T., Noort, M. W. J., Kremer, S., & Janssen, A. M. (2011) · Journal of Nutrition · doi:10.3945/jn.111.141366 · Cited by 110
The Science of Salt: Updating the evidence on global estimates of salt intake
Thout, S. R., Santos, J. A., McKenzie, B. L., Trieu, K., Johnson, C., McLean, R. M., Arcand, J., Campbell, N. R. C., & Webster, J. L. (2019) · Journal of Clinical Hypertension · doi:10.1111/jch.13546 · Cited by 108
Reducing salt intake to prevent hypertension and cardiovascular disease
He, F. J., Campbell, N. R. C., & MacGregor, G. A. (2012) · Revista Panamericana de Salud Pública · doi:10.1590/s1020-49892012001000008 · Cited by 114
Iwahori, T., Miura, K., & Ueshima, H. (2017) · Nutrients · doi:10.3390/nu9070700 · Cited by 111
“Despite rigorous campaigns to reduce Na and increase K intake, a large gap remains between the recommended and actual intakes of both Na and K [18,19].”
BackgroundSalt in bread in Europe: potential benefits of reduction
Quı́lez, J., & Salas‐Salvadó, J. (2012) · Nutrition Reviews · doi:10.1111/j.1753-4887.2012.00540.x · Cited by 113
Low-salt diet increases insulin resistance in healthy subjects
Garg, R., Williams, G. H., Hurwitz, S., Brown, N. J., Hopkins, P. N., & Adler, G. K. (2010) · Metabolism · doi:10.1016/j.metabol.2010.09.005 · Cited by 108
“Our study is the largest study in healthy subjects, includes both men and women, was performed under carefully controlled conditions, and utilized a sodium content for the HS diet that is comparable to the average sodium intake in the US population [15].”
Method
Metadata
- Authors
- Brown, I. J., Tzoulaki, I., Candeias, V., & Elliott, P.
- Affiliations
- Imperial College London (GB)
- World Health Organization (CH)
- Corresponding author
- Elliott, P.
- Venue
- International Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-04-07
- Volume
- 38
- Issue
- 3
- Pages
- 791-813
- ISSN
- 0300-5771 (ISSN-L)
- 1464-3685
- OpenAlex
- W2154301407
- Cited by
- 1,173
- References
- 157
- Citations by year
- 2026: 13 · 2025: 31 · 2024: 33 · 2023: 61 · 2022: 66 · 2021: 87 · 2020: 94 · 2019: 81 · 2018: 78 · 2017: 90 · 2016: 98 · 2015: 109 · 2014: 95 · 2013: 92 · 2012: 61
- FWCI
- 46.14
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Epidemiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- World Health Organization
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Sodium Intake and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Keywords
- sodium intake, salt reduction, sodium excretion, INTERSALT, INTERMAP, sodium sources, processed foods, soy sauce, blood pressure, cardiovascular health, salt reduction policy, cross-national comparison
- MeSH terms
- Adolescent, Adult, Cardiovascular Diseases, Child, Child, Preschool, Cooking, Cross-Cultural Comparison, Diet, Feeding Behavior, Female, Health Promotion, Humans, Hypertension, Infant, Infant, Newborn, Health Knowledge, Attitudes, Practice, Male, Middle Aged, Global Health, Sodium Chloride, Dietary, Young Adult
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