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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food sources of sodium are presented for several Asian, European and Northern American countries, including previously unpublished INTERMAP data.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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“[1] However, the daily salt intake worldwide, particularly in Asian countries, was approximately 9 g to 12 g, which is more than doubled the World Health Organization (WHO) recommendation.[2] Therefore, a population reduction in salt intake is of high priority.”
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“Natural sodium levels in foods account for about 10% of dietary intake, whereas processed foods and foods in restaurants are estimated to contribute over 75–90% of dietary sodium (Brown et al., 2009; Garriguet, 2007; Jacobson et al., 2013; U.S. Department of Agriculture, 2010).”
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“Globally, it was estimated that sodium intake in children older than five years of age was in excess by about 100 mmol/day.(49) This was a significantly high sodium intake level, considering that a high level of salt intake in infancy and childhood correlated to a high BP later in life.”
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“There is also increasing evidence to suggest that high sodium intake increases the risk of stomach cancer, osteoporosis and obesity.(1) 2 Thus, reducing sodium or salt intake has been identified as a priority intervention to reduce non-communicable diseases (NCD).”
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“However, self-report, memory, and ability to estimate portion size and discretionary salt usage also contributed to the potential for error.(43,63,64) This justifies the use of a food frequency style questionnaire that is based on food behavior and intake patterns rather than having to accurately estimate portion size.”
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“This high sodium intake is predominantly due to the high levels of sodium present in the food supply rather than salt added by consumers((4)) and to food consumed outside the home((3)).”
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“An emerging body of evidence has proved that high salt intake is associated with an elevated risk of hypertension((31)).”
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“However, this requires strict observance of the prescription,(31,32) and various allergic reactions have been reported.(33) Moreover, various factors can affect urinary excretion of creatinine, including muscle mass, consumption of protein-rich foods, intense physical activity, age, and weight.”
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“Therefore, popular processed meals, such as ‘‘fast food’’, contain approximately 100 times more sodium chloride than homemade meals [124, 125].”
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“sodium content could plausibly lead to greater awareness of salt in this population (Brown et al., 2009).”
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Qin, Y., Melse‐Boonstra, A., Pan, X., Zhao, J., Yuan, B., Dai, Y., Zhou, M., Geleijnse, J. M., Kok, F. J., & Shi, Z. (2014) · BMC Public Health · doi:10.1186/1471-2458-14-948 · Cited by 32
“Salt intake has been acknowledged as a direct risk factor for hypertension [29].”
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“High on the list of priorities has been the need for alternative methods by which to document population levels of salt consumption, with gold standard 24 hr urine collections being deemed too onerous and too costly for many resource poor settings [43].”
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“High intakes are explained mainly by the contribution of salt from processed or restaurant-prepared foods((5)).”
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“Consequently, children frequently consume more dietary sodium than recommended [2], as sodium chloride is the main contributor to sodium intake (~90”
Energy and nutrient intakes of young children in the UK: findings from the Gemini twin cohort
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“High intakes of Na are associated with elevated blood pressure and adverse cardiovascular health in adults((27)).”
Sales, C. H., Fontanelli, M. D. M., Vieira, D. A. S., Marchioni, D. M. L., & Fisberg, R. M. (2017) · British Journal Of Nutrition · doi:10.1017/s0007114516004633 · Cited by 28
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“In addition, a written questionnaire of alimentary habits, validated by the World Health Organization (WHO) and the Pan-American Health Organization (PAHO), was employed [29, 30].”
MethodRNA-seq analyses the effect of high-salt diet in hypertension
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Low Salt Diet and Insulin Resistance
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“The United Kingdom is making efforts to lower its sodium intake to 3 grams by the year of 2025 [8].”
BackgroundSalt, aldosterone and extrarenal Na+ - sensitive responses in pregnancy
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“The recommended level of dietary salt intake is 5 g per day, which equates to around 2000 mg of Naþ [2], however dietary salt intake is above this recommended daily amount in a majority of countries [3].”
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“It is well known that the mean daily salt intake is excessive in most western countries (between 7 and 18 g) and even higher in Asia, and in excess compared to the World Health Organization recommendations (<5 g daily; Brown et al., 2009).”
BackgroundDietary sodium intake in urban and rural Malawi, and directions for future interventions
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“The majority of sodium intake in many high-income settings comes from processed foods, which historically have not been a substantial part of the diet in SSA (10, 15, 16).”
BackgroundInfluentialSucrose release from agar gels: Effects of dissolution order and the network inhomogeneity
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“Additionally, meat products (including processed meats such as ham, bacon, etc.) contribute to a high proportion of salt intake worldwide [41].”
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Evidence Relating Sodium Intake to Blood Pressure and CVD
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“populations.(19) About half of the participants said they were trying to reduce their salt intake and people who said that they sometimes or always added salt to food ate on average 1.”
BackgroundVega‐Vega, O., Fonseca-Correa, J. I., la Garza, A. M.-D., Rincón-Pedrero, R., Espinosa-Cuevas, Á., Baeza-Arias, Y. V., Dary, O., Herrero-Bervera, B., Nieves-Anaya, I., & Correa‐Rotter, R. (2018) · Nutrients · doi:10.3390/nu10070816 · Cited by 29
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“Globally, it is estimated that individuals consume between six and twelve grams of salt daily [8], far exceeding the WHO’s salt recommendation of five grams maximum [9].”
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“A less common initiative has been to alter the amount of daily sodium intake through the promotion of behavioral changes to reduce the amount of salt consumption at the household level [10].”
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The association of estimated salt intake with blood pressure in a Viet Nam national survey
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“Current intake above public health recommendations is not solely a United States-centric issue, but a global pandemic demonstrated by high intakes of sodium in other countries [39].”
BackgroundObesity, Cardiovascular and Neurodegenerative Diseases: Potential Common Mechanisms
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“The high NaCl levels ingested are obviously beyond common dietary intakes [37] so that the Endocrine (2016) 52:139–147 145”
BackgroundKey opportunities for sodium reduction in New Zealand processed foods
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“The majority of sodium (~75%) consumed in high-income countries comes from processed/packaged foods.(8) Consequently, there is increasing interest in reformulation of available foo d products to lower their sodium content.”
BackgroundBlood Pressure in Relation to Interactions Between Sodium Dietary Intake and Renal Handling
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“719 Excessive sodium in the human body, as a consequence of either increased dietary intake or decreased urinary excretion, is a well-established risk factor of hypertension.(1,2) In between-population cross-sectional studies, populations with higher dietary sodium intake had higher average levels of blood pressure an…”
BackgroundA Comparison of the Sodium Content of Supermarket Private-Label and Branded Foods in Australia
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“As 75% of dietary sodium is contributed by packaged processed foods [7] reducing added sodium in these foods would be a cost effective strategy to reduce the burden of preventable CVD [8–11].”
BackgroundKnowledge and Practices Related to Salt Intake among Saudi Adults
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Exploring alternative salting methods to reduce sodium content in blue-veined cheeses
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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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