Adherence to voluntary sodium reduction agreements in Brazil

Camila Zancheta Ricardo Giovanna Calixto Andrade Bianka Caliman Salvador Laís Amaral Mais Ana Clara Duran Ana Paula Bortoletto Martins About the authors

Resumo

O objetivo do trabalho foi avaliar a adesão aos acordos voluntários de redução de sódio firmados entre indústrias de alimentos e o Ministério da Saúde e comparar as metas adotadas com o limite de sódio proposto no modelo de perfil nutricional da Organização Pan-Americana da Saúde (OPAS). Utilizaram-se informações de 1.553 alimentos de 32 categorias incluídas nos acordos e comercializados nas maiores redes de supermercados brasileiras em 2017. Foram calculadas as proporções de produtos com quantidade de sódio igual ou abaixo do limite proposto pelos acordos e pela OPAS. A concordância de classificação dos itens segundo os dois critérios foi avaliada com o coeficiente kappa de Cohen (k). Nossos resultados mostraram que 77,7% dos alimentos analisados estavam adequados segundo os acordos de redução de sódio, porém apenas 35,9%, segundo o modelo da OPAS. A concordância entre os dois critérios ao classificar um produto como adequado em relação ao conteúdo de sódio foi fraca (k = 0,199). Conclui-se que os acordos voluntários de redução de sódio são limitados em relação à abrangência e ao rigor das metas estabelecidas. A adoção de medidas voltadas a todos os produtos disponíveis, com metas mais restritivas e obrigatórias, deveria ser considerada no país.

Palavras-chave:
Cloreto de sódio na dieta; Rotulagem de alimentos; Programas e políticas de nutrição e alimentação

Abstract

The objective was to assess adherence to voluntary agreements for sodium reduction firmed between the food industries and the Ministry of Health in Brazil and to compare their targets with the limit proposed in the Pan American Health Organization (PAHO) nutritional profile model. We used data from 1.553 foods from 32 categories included in the agreements and sold in the largest Brazilian supermarket chains in 2017. The frequency of products with sodium equal or below the cut-offs proposed by the voluntary agreements and by PAHO was calculated. Classification concordance according to the two was evaluated with Cohen’s kappa coefficient (k). Our results showed that 77.7% of products were adequate according to the voluntary agreements, and only 35.9% of them, according to the PAHO model. We identified a weak degree of concordance between both criteria in classifying a product as adequate about sodium content (k = 0.199). In conclusion, the voluntary agreements for sodium reduction are limited in their scope and rigor. The adoption of measures oriented for all products, with more restrictive and mandatory targets, should be considered in the country.

Key words:
Sodium chloride; Dietary; Food labeling; Nutrition programs and policies

Introduction

Non-communicable diseases (NCDs) are the leading cause of death worldwide, being responsible for more than 40 million deaths in 2016, which is equivalent to 71% of all deaths11 World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.. The NCDs that contribute most to the morbidity and mortality burden have several common modifiable lifestyle risk factors, including harmful use of alcohol, smoking, physical inactivity and unhealthy diet11 World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018..

One of the diet-related factors is excessive sodium consumption, which is associated with high blood pressure and the development of cardiovascular disease (CVD)22 Strazzullo P, D'Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 2009; 339:b4567.,33 He FJ, Tan M, Ma Y, MacGregor GA. Salt reduction to prevent hypertension and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2020; 75(6):632-647.. Worldwide mean sodium intake is 10 g/day, which is double the amount recommended by the World Health Organization (WHO). Government programs to reduce population intake of sodium are a cost effective means of preventing CVD and premature deaths44 Webb M, Fahimi S, Singh GM, Khatibzadeh S, Micha R, Powles J, Mozaffarian D. Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations. BMJ 2017; 356:i6699.. The WHO has prioritized sodium reduction to prevent and control NCDs, setting a target of a 30% relative reduction in mean population intake by 202555 World Health Organization (WHO). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO; 2013.. The Pan American Health Organization (PAHO) has also recognized that sodium consumption is a priority, launching a series of recommendations to reduce intake to less than 2 g or 5 g salt per person per day by 202066 Pan American Health Organization (PAHO). Salt-smart Americas: a guide for country-level action. Washington, DC: PAHO; 2013..

The situation in Brazil in relation to sodium intake, prevalence of NCDs and NCD deaths is similar to global trends. In 2016, it was estimated that NCDs accounted for 74% of total deaths, 28% of which were caused by CVD11 World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018., while sodium intake was double the WHO recommended limit11 World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.,77 Mill JG, Malta DC, Machado ÍE, Pate A, Pereira CA, Jaime PC, Szwarcwald CL, Rosenfeld LG. Estimation of salt intake in the Brazilian population: results from the 2013 National Health Survey. Rev Bras Epidemiol 2019; 22(Suppl. 2):E190009.SUPL.2.,88 Sarno F, Claro RM, Levy RB, Bandoni DH, Monteiro CA. [Estimated sodium intake for the Brazilian population, 2008-2009]. Rev Saude Publica 2013; 47(3):571-578.. Although the main sources of sodium in the country are table salt and salt-based condiments, data from Brazil’s household budget surveys conducted between 2003 and 2009 have shown that the contribution of processed and ultra-processed foods to sodium availability has increased significantly88 Sarno F, Claro RM, Levy RB, Bandoni DH, Monteiro CA. [Estimated sodium intake for the Brazilian population, 2008-2009]. Rev Saude Publica 2013; 47(3):571-578.. A study using consumption data from a household budget survey of 34,000 Brazilians aged over 10 years in 2009 showed that processed and ultra-processed food products accounted for more than half of dietary sodium99 Moura Souza A, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. Journal of the Academy of Nutrition and Dietetics 2013; 113(10):1359-1365..

In view of the above, since 2010, the Ministry of Health has been discussing strategies to reduce sodium intake, defining priority actions such as promoting the consumption of minimally processed staple foods, food education, guidance on nutrition labeling, and the reformulation of processed foods1010 Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Publica 2012; 32:6.. In 2011, the Ministry of Health and Brazilian Food Industry Association (ABIA) signed the first voluntary agreement aimed at reducing the sodium content of packaged foods sold in the country. Five agreements were signed between 2011 and 2017, setting sodium reduction targets for 35 food categories1111 Brasil. Termo de Compromisso 004/2011 de 7 de abril de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011. p. 81.

12 Brasil. Termo de Compromisso 035/2011 de 13 de dezembro de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011.

13 Brasil. Termo de Compromisso de 5 de novembro de 2013. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2013.

14 Brasil. Termo de Compromisso de 28 de agosto de 2012. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2012. p. 124.
-1515 Brasil. Termo de Compromisso 005/2017 de 13 de junho de 2017. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2017.. It is worth mentioning that these agreements are part of the strategy to reduce population salt consumption to less than 5 g/day by 2020, in line with PAHO and WHO targets1111 Brasil. Termo de Compromisso 004/2011 de 7 de abril de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011. p. 81.

12 Brasil. Termo de Compromisso 035/2011 de 13 de dezembro de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011.

13 Brasil. Termo de Compromisso de 5 de novembro de 2013. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2013.

14 Brasil. Termo de Compromisso de 28 de agosto de 2012. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2012. p. 124.
-1515 Brasil. Termo de Compromisso 005/2017 de 13 de junho de 2017. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2017..

With the aim of providing evidence on sodium levels in packaged foods available on the Brazilian market and helping shape national policies to reduce population intake of this nutrient, this study assessed compliance with voluntary sodium reduction targets for packaged food products sold in the country and compared the amount of sodium in these foods to the limits recommended by the PAHO for the prevention of NCDs.

Methods

The data were collected between April and July 2017 by photographing the labels of foods sold by Brazil’s biggest supermarket chains in São Paulo and Salvador1616 Euromonitor International. Grocery retailers in Brazil. 2016.. São Paulo was chosen because it is the country’s largest city. As one of the selected supermarket chains only has stores in the country’s Northeast region, the data from the products sold by this chain were collected in Salvador, the largest city in the region.

All stores owned by the respective supermarket chains in the selected locations were georeferenced and the socioeconomic status of the surrounding areas was determined based on the average family head income in census tracts within a 1,000-meter radius, using data from the latest census (2010)1717 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2010. Rio de Janeiro: IBGE; 2010.. The stores were then divided into income terciles and the largest outlets in terms of area in the first and third terciles were included in the sample. Two outlets from each chain were visited, except for one chain, which stipulated that data could only be collected in its distribution centers, where all the products were available. Data collection followed the approach proposed by the International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support (INFORMAS), described in detail by Kanter et al.1818 Kanter R, Reyes M, Corvalán C. Photographic methods for measuring packaged food and beverage products in supermarkets. Curr Dev Nutr 2017; 1(10):e001016.. Formal permission for data collection was obtained from the supermarket chains.

Photographs were taken of all sides of the packaging. The data were entered into the REDCap platform using a form developed by the University of North Carolina at Chapel Hill and Institute of Nutrition and Food Technology in Chile adapted for use in the present study. Duplicate products, different package sizes, packages that contained multiple individual items, and products without information were excluded, resulting in 11,434 products.

Only products from the 35 food categories included in the voluntary agreements signed before data collection were analyzed (Chart 1). The agreement signed in 2017, setting new targets for instant noodles, sliced bread and mini bread rolls for 2018 and 2020, was therefore not considered1515 Brasil. Termo de Compromisso 005/2017 de 13 de junho de 2017. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2017.. We did not find any items in the categories ‘bread roll’, ‘roulade’ and ‘liquid/gelatinous stock’. The final sample comprised 1,553 items from 32 food categories.

Chart 1
Summary of the voluntary cooperation agreements between the Ministry of Health and food industry for the reduction of sodium in foods in Brazil.

The following descriptive statistics were used to analyze the data: means and standard deviations; 25th, 50th and 75th percentiles; and minimum and maximum sodium content in each food category. The Shapiro-Wilk test was used to determine whether the sodium content data were normally distributed, adopting a significance level of p ≤ 0.05. For most of the categories (20 of 32, or 62.5%), the data did not have a normal distribution. As the reduction targets were set based on mean sodium content, both mean and median sodium content are presented.

To assess adherence to the voluntary agreements, we calculated the prevalence of products with sodium content below the latest targets set for each respective category. As we collected all products, regardless of manufacturer, we analyzed whether brands with at least five products with sodium content above the targets belonged to companies that signed the agreements.

We also verified compliance with the PAHO Nutrient Profile Model, which establishes the following criterion for identifying products excessive in sodium: ≥ 1 mg of sodium per 1 kcal 1919 Pan American Health Organization (PAHO). Pan American Health Organization Nutrient Profile Model. Washington, DC: PAHO; 2016.. This tool was developed to help PAHO member countries identify inappropriate nutrient profiles in non-alcoholic foods and beverages covered by regulations to prevent and control diet-related NCDs1919 Pan American Health Organization (PAHO). Pan American Health Organization Nutrient Profile Model. Washington, DC: PAHO; 2016..

We chose this criterion to assess the rigor of the voluntary agreements, as it is consistent with discussions on policies in the region and because, as far as we know, the PAHO and WHO have yet to develop specific thresholds for the reformulation of products containing sodium.

Level of agreement for the classification of the foods based on the thresholds proposed by the voluntary agreements and PAHO was determined using the Cohen’s kappa coefficient (k). The following classifications were used to assess the extent of agreement between the methods: poor, k < 0.00; slight, 0.00 ≤ k ≤ 0.20; fair, 0.21 ≤ k ≤ 0.40; moderate, 0.41 ≤ k ≤ 0.60; substantial, 0.61 ≤ k ≤ 0.80; and almost perfect, k > 0.802020 Watson PF, Petrie A. Method agreement analysis: a review of correct methodology. Theriogenology 2010; 73(9):1167-1179..

The analyses were performed using Stata version 16.0.

Results

Table 1 shows sodium content by food category. The categories with the highest sodium content were condiments [‘rice seasoning’ (mean 20,075.7; median 19,730.0 mg/100g), ‘stock cubes/powder’ (mean 20,029.7; median 20,505.3 mg/100g), ‘seasoning paste’ (mean 19,596.2; median 26,840.0 mg/100g), ‘other types of seasoning’ (mean 13,807.7; median 14,780.0 mg/100g)] and meat products [‘refrigerated mortadella’ (mean 1,443.5 ; median 1,320.0 mg/100g ), ‘mortadella kept at room temperature’ (mean 1,417.9; median 1,350.0 mg/100g), ‘hams’ (mean 1,329,9; median 1,160.0 mg/100g), ‘cooked sausage kept at room temperature’ (mean 1,193.6; median 1,187.0 mg/100g) and ‘refrigerated cooked sausage’ (mean 1,136.6; median 1,320.0 mg/100g)]. Mean sodium content was above the voluntary targets in 25.0% of the 32 categories (‘sponge cake mix’, ‘moist cake mix’, ‘salty corn snacks’, ‘savory cookies’, ‘cheese spread’, ‘refrigerated mortadella’, ‘mortadella kept at room temperature’ and ‘hams’). Median sodium content was above the targets in four categories (‘sponge cake mix’, ‘moist cake mix’, ‘uncooked sausage’ and ‘refrigerated mortadella’).

Table 1
Number of foods and sodium content in milligrams per 100 g of the product, by food category.

Table 2 shows the proportion of foods that met the limits proposed by the voluntary sodium reduction agreements and PAHO Nutrient Profile Model. Considering the overall sample, 77.7% met the voluntary sodium reduction targets. The categories with the largest proportion of products that met the voluntary targets were ‘mini bread rolls’ (100.0%) and ‘rice seasoning’ (100.0%), followed by ‘breakfast cereal’ (97.5%), ‘breaded foods’ (95.3%) and ‘mayonnaise’ (95.2%). The category with the smallest proportion of products that met the limits was ‘refrigerated mortadella’ (23.8%), followed by ‘sponge cake mix’ (29.5%), ‘moist cake mix’ (37.5%) and ‘uncooked sausage’ (45.0%). The products with sodium content above the limits belonged to more than 100 brands. Seventeen of these brands had at least five products that failed to comply with the limits. Together, these brands accounted for 52.7% of the items that that failed to comply (183 of 347). Seven of these brands belonged to companies linked to the food associations that signed the voluntary agreements. Of the remaining 10, four were supermarket brands.

Table 2
Proportion of foods with sodium content equal to or below the limits set out in the voluntary sodium reduction agreements and PAHO Nutrient Profile Model and agreement between the two criteria. by food category.

Only 35.9% of the foods met the limits proposed by the PAHO. The category with the largest proportion of items within the limit was ‘moist cake mix’ (100.0%), followed by ‘sandwich cookies’ (99.0%), ‘sweet cookies’ (94.6%), ‘breakfast cereal’ (92.4%) and ‘sandwich cakes’ (91.3%). In almost a third of the categories (31.3%), none of the products were within the limits proposed by the PAHO Nutrient Profile Model, and in 16 categories (50.0%) the proportion of foods with appropriate sodium content was 50% or less.

Considering the overall sample, agreement between the two criteria was slight (kappa = 0.199). Only five categories showed substantial agreement or above (k>0.60):‘chips/potato sticks’, ‘sponge cake mix’, ‘cake without filling’, ‘sandwich cakes’ and ‘sweet cookies’. The large majority of the categories (23 of 32, or 71.9%) showed slight or poor agreement.

Discussion

Our findings show that around a quarter of the products belonging to the categories included in the voluntary agreements failed to meet the sodium reduction targets set to be achieved by 2017. An even larger proportion (64.1%) had a sodium content above the limit proposed by the PAHO Nutrient Profile Model. Agreement between the two criteria for the classification of products with high sodium content was slight, despite the fact that both criteria are aimed at preventing NCDs.

Recent studies have pointed to a progressive reduction in the sodium content of foods sold in Brazil and, overall, a large proportion of products comply with the voluntary targets. In a study assessing 20 categories included in the first voluntary agreements, Nilson et al. found a significant reduction in the mean sodium content of foods in 13 categories between 2011 and 2017, ranging from 8 to 34%2121 Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L'Abbé M, Jaime PC. Sodium reduction in processed foods in Brazil: analysis of food categories and voluntary targets from 2011 to 2017. Nutrients 2017; 9(7):742.. Another study including the same food categories reported that more than 85% of the products analyzed in each category met the sodium targets between 2011 and 20132222 Nilson EAF, Spaniol AM, Gonçalves VSS, Oliveira ML, Campbell N, L'Abbé M, Jaime PC. The impact of voluntary targets on the sodium content of processed foods in Brazil, 2011-2013. J Clin Hypertens (Greenwich) 2017; 19(10):939-945..

The difference between our results and those of these studies may be explained by methodological differences. For example, we included all the categories and products covered by the agreements and targets set to be achieved by 2017. Some of the categories in our study with a lower proportion of products that meet the targets, such as sausages, mortadellas and hams, were recently added to the agreements and were not assessed by Nilson et al., who analyzed food categories in agreements signed in 20112222 Nilson EAF, Spaniol AM, Gonçalves VSS, Oliveira ML, Campbell N, L'Abbé M, Jaime PC. The impact of voluntary targets on the sodium content of processed foods in Brazil, 2011-2013. J Clin Hypertens (Greenwich) 2017; 19(10):939-945.. However, comparisons of some of the same categories (‘cake without filling’, ‘sponge cake mix’, ‘moist cake mix’, ‘salty corn snacks’ and ‘savory cookies’, for example) show a lower level of compliance than that reported by Nilson et al. This difference may be at least partially explained by the fact that, unlike Nilson et al., we included all of the relevant products found in the supermarkets, regardless of manufacturer, and not just those produced by ABIA member companies 2222 Nilson EAF, Spaniol AM, Gonçalves VSS, Oliveira ML, Campbell N, L'Abbé M, Jaime PC. The impact of voluntary targets on the sodium content of processed foods in Brazil, 2011-2013. J Clin Hypertens (Greenwich) 2017; 19(10):939-945.. Our findings show that most of the brands that contributed most to the items that failed to meet the targets did not belong to companies that are members of the food associations that signed the agreements. Despite the expected spillover effects of these agreements on non-signatory companies, our findings show that these initiatives had less effect on this group than on ABIA member companies. Thus, the changes to the sodium content of foods on the market may not be as pronounced as previously shown by Nilson et al. Brazil, for example, was the country with the lowest proportion of products meeting the lower regional target among 14 Latin American and Caribbean Countries2323 Arcand J, Blanco-Metzler A, Benavides Aguilar K, L'Abbe MR, Legetic B. Sodium levels in packaged foods sold in 14 Latin American and Caribbean countries: a food label analysis. Nutrients 2019; 11(2):369..

The comparison of the voluntary agreements and PAHO Nutrient Profile Model indicated that the two methods were discordant when classifying whether the sodium content of a product is compatible with NCD prevention. The sodium reduction targets in the voluntary agreements were set based on mean values in each category after excluding outliers, leaving out a large proportion of the products that already met the targets. The Brazilian targets were set mainly focusing on products with high levels of sodium and are not capable of ensuring that products from different categories have appropriate nutrient profiles2424 Martins APB. Redução de sódio em alimentos: uma análise dos acordos voluntários no Brasil. São Paulo: Instituto Brasileiro de Defesa do Consumidor; 2014.. Salt reduction targets in the United Kingdom, for example, cover a larger number of food categories (around 80) and are generally more rigorous, particularly for meat products such as sausages and hamburgers2525 Public Health England (PHE). Salt reduction targets for 2017. London: PHE; 2017.. Some of the included categories in the United Kingdom, such as pizzas and sandwiches, also contain high levels of sodium in Brazil2626 Souza AM, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. J Acad Nutr Diet 2013; 113(10):1359-1365., yet are not covered by the agreements. Deficiencies in monitoring is a factor that limits the effectiveness of voluntary agreements in the prevention and control of NCDs. A study that evaluated technical reports published by Brazil’s National Health Surveillance Agency (ANVISA), which, together with the Ministry of Health, is responsible for monitoring reduction targets, showed that food categories lacked standardization and the number of samples and regions included in the process were insufficient2727 Martins APB, Andrade GC, Bandoni DH. Avaliação do monitoramento do teor de sódio em alimentos: uma análise comparativa com as metas de redução voluntárias no Brasil. Vigil Sanit Debate 2015; 3:9..

Various countries have adopted measures to reduce population intake of sodium2828 Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6(8):3274-3287.; however, estimates suggest that consumption exceeds recommended levels for the prevention of NCDs in all countries and regions2929 Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, Ezzati M, Engell RE, Lim SS, Danaei G, Mozaffarian D; Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE). Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3(12):e003733.. Some countries, such as the United Kingdom and Finland, have been successful in implementing voluntary programs with the food industry and have managed to reduce salt levels, population intake, blood pressure levels, and associated diseases over recent decades3030 He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2009; 23(6):363-384.

31 Laatikainen T, Pietinen P, Valsta L, Sundvall J, Reinivuo H, Tuomilehto J. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. Eur J Clin Nutr 2006; 60(8):965-790.
-3232 Laverty AA, Kypridemos C, Seferidi P, Vamos EP, Pearson-Stuttard J, Collins B, Capewell S, Mwatsama M, Cairney P, Fleming K, O'Flaherty M, Millett C. Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study. J Epidemiol Community Health 2019; 73(9):881-887.. Despite progress in Finland, which reduced population salt intake from 12 to around 9 g/day between 1979 and 2002, Laatikainen et al. estimate that, if the decrease in intake were to follow the same trend, it would take another 35 years for men and 26 years for women to achieve an intake of 5 g3131 Laatikainen T, Pietinen P, Valsta L, Sundvall J, Reinivuo H, Tuomilehto J. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. Eur J Clin Nutr 2006; 60(8):965-790.. More recently, Argentina and South Africa introduced legislation limiting salt levels in a range of food categories. The advantages of mandatory reformulation include the possibility of imposing fiscal penalties, the fact that regulations apply to all manufacturers, and the stability of measures with changes of government2828 Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6(8):3274-3287.. However, critics of reformulations aimed at reducing the intake of critical nutrients such as sodium suggest that the strategy has important limitations. These include the fact that it is not possible to ensure that reformulated ultra-processed products have an appropriate nutrient profile and one of the policy rationales behind such measures is that reformulation is a means of reducing the consumption of these nutrients without changing dietary patterns, which can legitimate the consumption of these foods3333 Scrinis G, Monteiro CA. Ultra-processed foods and the limits of product reformulation. Public Health Nutr 2018; 21(1):247-252..

Other strategies can be employed to reduce population intake of sodium besides reformulation. These include the use of taxes and adequate nutrient labelling, including front-of-package warnings indicating that a product is high in one or more nutrients of concern. In 2014, Mexico created a tax on sugary drinks and non-essential high energy density foods such as salty snacks, candies and breakfast cereals. A study showed that one year after the introduction of the measure, purchases of the taxed products had fallen3434 Batis C, Rivera JA, Popkin BM, Taillie LS. First-Year evaluation of Mexico's tax on nonessential energy-dense foods: an observational study. PLoS Med 2016; 13(7):e1002057.. In Hungry, a tax on unhealthy foods such as salty snacks was also effective in reducing the consumption of products in the food categories and promoting more healthy food choices, both due to price and increased awareness about the products3535 World Health Organization (WHO). Assessment of the impact of a public health product tax. Budapest: WHO; 2015.. The use of front-of-package warnings is also mentioned by the report “Salt-smart Americas: a guide for country-level action” as a useful complement to the reformulation of foods with the aim of reducing population intake of sodium66 Pan American Health Organization (PAHO). Salt-smart Americas: a guide for country-level action. Washington, DC: PAHO; 2013.. In Latin America, Chile, Uruguay, Peru and Mexico have adopted front-of-package warning labels. Studies in Brazil demonstrate that the presence of warnings indicating that a product is high in critical nutrients can help consumers make more healthy food choices3636 Sato PM, Mais LA, Khandpur N, Ulian MD, Bortoletto Martins AP, Garcia MT, Spinillo CG, Urquizar Rojas CF, Jaime PC, Scagliusi FB. Consumers' opinions on warning labels on food packages: A qualitative study in Brazil. Plos One 2019; 14(6):e0218813.,3737 Khandpur N, Sato PM, Mais LA, Bortoletto Martins AP, Spinillo CG, Garcia MT, Urquizar Rojas CF, Jaime PC. Are front-of-package warning labels more effective at communicating nutrition information than traffic-light labels? A randomized controlled experiment in a Brazilian sample. Nutrients 2018; 10(6):688..

The present study stands out because of the size and broad scope of the sample of packaged foods. However, it does have some limitations. The number of products found in some food categories was small and the possibility of losses of some foods cannot be ruled out. However, previous studies also found a small number of foods in certain categories2121 Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L'Abbé M, Jaime PC. Sodium reduction in processed foods in Brazil: analysis of food categories and voluntary targets from 2011 to 2017. Nutrients 2017; 9(7):742.,2222 Nilson EAF, Spaniol AM, Gonçalves VSS, Oliveira ML, Campbell N, L'Abbé M, Jaime PC. The impact of voluntary targets on the sodium content of processed foods in Brazil, 2011-2013. J Clin Hypertens (Greenwich) 2017; 19(10):939-945., indicating limited product variety. Another limitation is the fact that we did not include other types of food outlets. However, supermarkets are the most commonly used outlet for food shopping in Brazil and provide around 60% of the calories purchased for household consumption3838 Machado PP, Claro RM, Canella DS, Sarti FM, Levy RB. Price and convenience: The influence of supermarkets on consumption of ultra-processed foods and beverages in Brazil. Appetite 2017; 116:381-388.. Furthermore, we used the information displayed by the manufacturers on the food labels, without performing laboratorial analyses to verify the stated content. Finally, we did not consider the market share of the products and were therefore unable to identify the sodium content of the most commonly consumed products in Brazil.

Considering that sodium intake in the country is more than twice the recommended threshold and the growing consumption of ultra-processed foods, more rigorous regulations need to be put in place in order to achieve Brazil’s population sodium intake reduction target. The deadline for the voluntary sodium reduction targets was 2020 and trends indicate that Brazil is far from achieving the desired population intake. We recommend that measures be expanded to cover more product categories, focusing especially on ultra-processed foods like pizzas and sandwiches, and the development of stricter targets as in other countries, ideally closer to the level proposed by the PAHO for the prevention of NCDs. Finally, it is important to highlight the limitations of voluntary agreements in comparison to mandatory regulations, meaning that priority should be given to the latter. Other measures such as high sodium content warning labels and education to raise public awareness of the use and consumption of salt should be implemented alongside these strategies in order to reduce population intake of sodium.

References

  • 1
    World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.
  • 2
    Strazzullo P, D'Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 2009; 339:b4567.
  • 3
    He FJ, Tan M, Ma Y, MacGregor GA. Salt reduction to prevent hypertension and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2020; 75(6):632-647.
  • 4
    Webb M, Fahimi S, Singh GM, Khatibzadeh S, Micha R, Powles J, Mozaffarian D. Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations. BMJ 2017; 356:i6699.
  • 5
    World Health Organization (WHO). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO; 2013.
  • 6
    Pan American Health Organization (PAHO). Salt-smart Americas: a guide for country-level action. Washington, DC: PAHO; 2013.
  • 7
    Mill JG, Malta DC, Machado ÍE, Pate A, Pereira CA, Jaime PC, Szwarcwald CL, Rosenfeld LG. Estimation of salt intake in the Brazilian population: results from the 2013 National Health Survey. Rev Bras Epidemiol 2019; 22(Suppl. 2):E190009.SUPL.2.
  • 8
    Sarno F, Claro RM, Levy RB, Bandoni DH, Monteiro CA. [Estimated sodium intake for the Brazilian population, 2008-2009]. Rev Saude Publica 2013; 47(3):571-578.
  • 9
    Moura Souza A, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. Journal of the Academy of Nutrition and Dietetics 2013; 113(10):1359-1365.
  • 10
    Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Publica 2012; 32:6.
  • 11
    Brasil. Termo de Compromisso 004/2011 de 7 de abril de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011. p. 81.
  • 12
    Brasil. Termo de Compromisso 035/2011 de 13 de dezembro de 2011. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2011.
  • 13
    Brasil. Termo de Compromisso de 5 de novembro de 2013. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2013.
  • 14
    Brasil. Termo de Compromisso de 28 de agosto de 2012. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2012. p. 124.
  • 15
    Brasil. Termo de Compromisso 005/2017 de 13 de junho de 2017. Estabelece as metas nacionais para a redução do teor de sódio em alimentos processados no Brasil. Brasília: Diário Oficial da União; 2017.
  • 16
    Euromonitor International. Grocery retailers in Brazil. 2016.
  • 17
    Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2010. Rio de Janeiro: IBGE; 2010.
  • 18
    Kanter R, Reyes M, Corvalán C. Photographic methods for measuring packaged food and beverage products in supermarkets. Curr Dev Nutr 2017; 1(10):e001016.
  • 19
    Pan American Health Organization (PAHO). Pan American Health Organization Nutrient Profile Model. Washington, DC: PAHO; 2016.
  • 20
    Watson PF, Petrie A. Method agreement analysis: a review of correct methodology. Theriogenology 2010; 73(9):1167-1179.
  • 21
    Nilson EAF, Spaniol AM, Gonçalves VSS, Moura I, Silva SA, L'Abbé M, Jaime PC. Sodium reduction in processed foods in Brazil: analysis of food categories and voluntary targets from 2011 to 2017. Nutrients 2017; 9(7):742.
  • 22
    Nilson EAF, Spaniol AM, Gonçalves VSS, Oliveira ML, Campbell N, L'Abbé M, Jaime PC. The impact of voluntary targets on the sodium content of processed foods in Brazil, 2011-2013. J Clin Hypertens (Greenwich) 2017; 19(10):939-945.
  • 23
    Arcand J, Blanco-Metzler A, Benavides Aguilar K, L'Abbe MR, Legetic B. Sodium levels in packaged foods sold in 14 Latin American and Caribbean countries: a food label analysis. Nutrients 2019; 11(2):369.
  • 24
    Martins APB. Redução de sódio em alimentos: uma análise dos acordos voluntários no Brasil. São Paulo: Instituto Brasileiro de Defesa do Consumidor; 2014.
  • 25
    Public Health England (PHE). Salt reduction targets for 2017. London: PHE; 2017.
  • 26
    Souza AM, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. J Acad Nutr Diet 2013; 113(10):1359-1365.
  • 27
    Martins APB, Andrade GC, Bandoni DH. Avaliação do monitoramento do teor de sódio em alimentos: uma análise comparativa com as metas de redução voluntárias no Brasil. Vigil Sanit Debate 2015; 3:9.
  • 28
    Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6(8):3274-3287.
  • 29
    Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, Ezzati M, Engell RE, Lim SS, Danaei G, Mozaffarian D; Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE). Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3(12):e003733.
  • 30
    He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2009; 23(6):363-384.
  • 31
    Laatikainen T, Pietinen P, Valsta L, Sundvall J, Reinivuo H, Tuomilehto J. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. Eur J Clin Nutr 2006; 60(8):965-790.
  • 32
    Laverty AA, Kypridemos C, Seferidi P, Vamos EP, Pearson-Stuttard J, Collins B, Capewell S, Mwatsama M, Cairney P, Fleming K, O'Flaherty M, Millett C. Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study. J Epidemiol Community Health 2019; 73(9):881-887.
  • 33
    Scrinis G, Monteiro CA. Ultra-processed foods and the limits of product reformulation. Public Health Nutr 2018; 21(1):247-252.
  • 34
    Batis C, Rivera JA, Popkin BM, Taillie LS. First-Year evaluation of Mexico's tax on nonessential energy-dense foods: an observational study. PLoS Med 2016; 13(7):e1002057.
  • 35
    World Health Organization (WHO). Assessment of the impact of a public health product tax. Budapest: WHO; 2015.
  • 36
    Sato PM, Mais LA, Khandpur N, Ulian MD, Bortoletto Martins AP, Garcia MT, Spinillo CG, Urquizar Rojas CF, Jaime PC, Scagliusi FB. Consumers' opinions on warning labels on food packages: A qualitative study in Brazil. Plos One 2019; 14(6):e0218813.
  • 37
    Khandpur N, Sato PM, Mais LA, Bortoletto Martins AP, Spinillo CG, Garcia MT, Urquizar Rojas CF, Jaime PC. Are front-of-package warning labels more effective at communicating nutrition information than traffic-light labels? A randomized controlled experiment in a Brazilian sample. Nutrients 2018; 10(6):688.
  • 38
    Machado PP, Claro RM, Canella DS, Sarti FM, Levy RB. Price and convenience: The influence of supermarkets on consumption of ultra-processed foods and beverages in Brazil. Appetite 2017; 116:381-388.

Publication Dates

  • Publication in this collection
    02 Feb 2022
  • Date of issue
    Feb 2022

History

  • Received
    07 Aug 2020
  • Accepted
    15 Jan 2021
  • Published
    17 Jan 2021
ABRASCO - Associação Brasileira de Saúde Coletiva Av. Brasil, 4036 - sala 700 Manguinhos, 21040-361 Rio de Janeiro RJ - Brazil, Tel.: +55 21 3882-9153 / 3882-9151 - Rio de Janeiro - RJ - Brazil
E-mail: cienciasaudecoletiva@fiocruz.br