Abstract:

This study aimed at assessing the potential impact of the reduction of sodium content in processed foods in the average salt intake in the Brazilian population. A total of 32,900 participants of the first National Dietary Survey (NDS 2008-2009), age 10 years and older who provided information about food intake over two days were evaluated. The sodium reduction targets established by the Brazilian Ministry of Health in 2010 and 2013 were used as the reference to determine the maximum content of sodium in 21 groups of processed food. The results show that sodium reduction targets in processed food have small impact in mean Brazilian population intake of salt. For 2017, the expected mean reduction is of 1.5%, the average sodium intake being still above the recommended 2,000mg/day maximum. Therefore, it will hardly be possible to reach the necessary reduction in salt intake in Brazil from volunteer agreements like the ones made so far.

Keywords:
Sodium; Dietary Sodium; Industrialized Foods; Diet Surveys

Introduction

Excessive salt intake is associated with a progressive increase of blood pressure, and therefore to an increase in the risk of cardiovascular diseases, which are the main cause of deaths in Brazil and worldwide ¹1. Strazzullo P, D'Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 2009; 339:b4567.^{), (2}2. Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377:1949-61.. In 2013, the prevalence of self-reported high blood pressure in the Brazilian population was 24% ³3. Ministério da Saúde. Vigitel Brasil 2013: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_2013.pdf (acessado em 20/Abr/2015).
http://bvsms.saude.gov.br/bvs/publicacoe... .

According to data from the first National Dietary Survey (NDS) conducted in 2008-2009, the average salt intake among the Brazilian population was 3,190mg/day4, which is higher than the maximum tolerable level of 2,000mg/day for adults, as recommended by the World Health Organization (WHO) ⁵5. World Health Organization. Guideline: sodium intake for adults and children http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf?ua=1&ua=1 (acessado em 10/Ago/2015).
http://apps.who.int/iris/bitstream/10665... . According to Sarno et al. ⁶6. Sarno F, Claro RM, Levy RB, Bandoni DH, Monteiro CA. Estimativa de consumo de sódio pela população brasileira, 2008-2009. Rev Saúde Pública 2013; 47:571-8., the intake of processed foods accounted for a mean salt intake increase from 17.2% to 20.5%.

In Brazil, the Ministry of Health has been coordinating national strategies aimed at reducing sodium intake, in addition to making agreements with the food industry for a gradual reduction in salt levels in the processed food categories considered as priority ⁷7. Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Pública 2012; 34:287-92.^{), (8}8. Ministério da Saúde. Extrato de Compromisso nº 4/2011. Termo de compromisso por intermédio do Ministério da Saúde e a Associação Brasileira de Indústrias de Alimentação (ABIA), a Associação Brasileira de Indústrias de Massas Alimentícias (ABIMA), a Associação Brasileira da Indústria de Trigo (ABITRIGO) e a Associação Brasileira da Indústria de Panificação e Confeitaria (ABIP). Diário Oficial da União 2011; 8 abr.^{), (9}9. Ministério da Saúde. Extrato de Compromisso nº 35/2011. Termo de compromisso que firmam entre si a União, por intermédio do Ministério da Saúde, e a Associação Brasileira de Indústrias de Alimentação - ABIA, a Associação Brasileira de Indústrias de Massas Alimentícias - ABIMA, a Associação Brasileira da Indústria de Trigo - ABITRIGO e a Associação Brasileira da Indústria de Panificação e Confeitaria - ABIP. Diário Oficial da União 2011; 26 dez.^{), (10}10. Ministério da Saúde. Extrato do Termo de Compromisso. Termo de Compromisso que firmam entre o Ministério da Saúde, e a Associação Brasileira das Indústrias de Alimentação - ABIA. Diário Oficial da União; 2013; 17 out.^{), (11}11. Ministério da Saúde. Extrato de Compromisso. Termo de compromisso que firmam entre si a União, por intermédio do Ministério da Saúde, a Associação Brasileira de Indústrias de Alimentação - ABIA, a Associação Brasileira das Indústrias de Queijos - ABIQ, a Associação Brasileira da Indústria Produtora e Exportadora de Carne Suína - ABIPECS, Sindicato da Indústria de Carnes e Derivados no Estado de São Paulo - SINDCARNES e União Brasileira de Avilcutura - UBABEF. Diário Oficial da União 2013; 13 dez.. The aim of this investigation was to assess the potential impact of sodium content reduction in processed foods on the overall sodium intake in Brazil.

Methods

This study used data from the NDS, conducted in 2008-2009, in a subsample of 24% of the 55,790 families surveyed in the 2008-2009 Household Budget Survey conducted by the Brazilian Institute of Geography and Statistics (IBGE) ¹²12. Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011..

The goal of the NDS was to collect food-intake data of all residents of the selected households, age 10 years and over. Food intake was estimated from the average intake recorded in two nonconsecutive days. A total of 32,900 NDS participants who provided data of their intake over two days were assessed.

The amount of grams of food intake and their sodium content in milligrams (mg) were estimated with the use of the Table of Reference Measures and Table of Nutritional Composition of Food Consumed in Brazil, respectively, both developed by the IBGE ¹²12. Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011..

Salt reduction targets, agreed upon by the Brazilian Ministry of Health and the food industry associations, in 2011, to be reached the at completion of five years after the agreement, were used as the reference to determine the maximum amount of sodium in processed food categories considered a priority. The criteria were: (1) international references about sodium reduction; (2) lower limit of sodium content in the respective category, in the domestic market; (3) adjusted means of sodium levels and/or amount found in at least 50% of the products of the category found in the domestic market ⁷7. Nilson EAF, Jaime PC, Resende DO. Iniciativas desenvolvidas no Brasil para a redução do teor de sódio em alimentos processados. Rev Panam Salud Pública 2012; 34:287-92.^{), (8}8. Ministério da Saúde. Extrato de Compromisso nº 4/2011. Termo de compromisso por intermédio do Ministério da Saúde e a Associação Brasileira de Indústrias de Alimentação (ABIA), a Associação Brasileira de Indústrias de Massas Alimentícias (ABIMA), a Associação Brasileira da Indústria de Trigo (ABITRIGO) e a Associação Brasileira da Indústria de Panificação e Confeitaria (ABIP). Diário Oficial da União 2011; 8 abr.^{), (9}9. Ministério da Saúde. Extrato de Compromisso nº 35/2011. Termo de compromisso que firmam entre si a União, por intermédio do Ministério da Saúde, e a Associação Brasileira de Indústrias de Alimentação - ABIA, a Associação Brasileira de Indústrias de Massas Alimentícias - ABIMA, a Associação Brasileira da Indústria de Trigo - ABITRIGO e a Associação Brasileira da Indústria de Panificação e Confeitaria - ABIP. Diário Oficial da União 2011; 26 dez.^{), (10}10. Ministério da Saúde. Extrato do Termo de Compromisso. Termo de Compromisso que firmam entre o Ministério da Saúde, e a Associação Brasileira das Indústrias de Alimentação - ABIA. Diário Oficial da União; 2013; 17 out.^{), (11}11. Ministério da Saúde. Extrato de Compromisso. Termo de compromisso que firmam entre si a União, por intermédio do Ministério da Saúde, a Associação Brasileira de Indústrias de Alimentação - ABIA, a Associação Brasileira das Indústrias de Queijos - ABIQ, a Associação Brasileira da Indústria Produtora e Exportadora de Carne Suína - ABIPECS, Sindicato da Indústria de Carnes e Derivados no Estado de São Paulo - SINDCARNES e União Brasileira de Avilcutura - UBABEF. Diário Oficial da União 2013; 13 dez. (Table 1).

For the targets to be found, initially the mean amount of sodium (mg Na/100g of food) was calculated for each of the 21 food groups or items considered a priority. The sum of sodium content in each food group was divided by the amount of grams intake multiplied by 100. Mean sodium intake estimates (mg/day) were calculated for the years 2013, 2016 and 2017, taking in consideration the agreed sodium content reduction, with the overall average reduction proportion calculated at the completion of five years after the agreement. Afterward, for 2017, a further 25% reduction was added to the food whose maximum sodium content agreed upon was higher than the mean estimated by the 2008-2009 NDS, and to the food whose agreed reduction was lower than 25%. This proportion was chosen because, at this salt reduction level, no change in flavor is detected by the consumer ¹³13. Grigis 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; 57:616-20.. The analyses were stratified according to sex and age group (10-19 years, 20-59 years, and 60 years and older).

All analyses took into consideration the sample weight and the study design, and were performed using SAS version 9.1.3 software (SAS Inst., Cary, USA).

The NDS was approved by the Ethics Research Committee of the Social Medicine Institute, State University of Rio de Janeiro , registry filing number CAAE 0011.0259.000-11.

Results

The maximum content of sodium agreed upon was higher than the estimated amount based on the food composition table, except for filling cookies, savory biscuit, bread loaf, breakfast cereal, mayonnaise, ham, French fries, sweet biscuit, soups, and French roll (Table 1).

The estimated mean sodium intake reduction 5 years after the agreement was 1.5%. After applying the 25% reduction for the year 2017, the estimated mean reduction was 6.3% (Table 2). The mean sodium intake reduction was similar among the sex and age groups, ranging between 5.6% among male adults and 7.6% among women.

Discussion

The goals of salt reduction in processed foods have small impact in the average sodium intake by the Brazilian population, which remains above the maximum recommended limit of 2,000mg/day. The estimated reduction is below the 20% observed by Grimes et al. ¹⁴14. Grimes CA, Campbell KJ, Riddell LJ, Nowson CA. Sources of sodium in Australian children's diets and the effect of the application of sodium targets to food products to reduce sodium intake. Br J Nutr 2011; 105:468-77., who assessed the reduction of sodium in processed foods in the average salt intake of Australian children and adolescents. However, the food intake standards of countries like Australia are quite different than Brazil's, and that should be taken into account when assessing the impact of these policies. In addition, a possible explanation for our findings is the fact that higher proportion of reduction had been agreed upon for food with lower sodium content. For instance, for the filling cookies, with sodium density of 405mg/100g, the total reduction proportion agreed upon was 34.6%. However, when compared to ham, whose sodium density is 1,313mg/100g, about three times higher than the cookie's, the agreed reduction was 11.6%, around three times lower.

Most of the reduction amounts agreed upon were higher than the mean sodium content estimates presented in the 2008-2009 NDS nutritional composition table. This fact may be explained by differences between the brands of food included in the table and the brands analyzed to determine the mean content agreed upon. Moreover, there is no knowledge about the market share of the brands of food included in the agreements.

In 2013, WHO established a 30% global reduction goal for the total sodium intake by 2025, and one of the key actions is to reduce the content of sodium in processed products ¹⁵15. World Health Organization. A comprehensive global monitoring framework including indicators and a set of voluntary global targets for the prevention and control of non-communicable diseases. http://www.who.int/nmh/events/2012/ discussion_paper2_20120322.pdf (acessado em 20/Abr/2015).
http://www.who.int/nmh/events/2012/ disc... . Some 17 countries have developed volunteer or legally imposed sodium content reduction in processed foods, with bread being the main target of these actions ¹⁶16. Webster J, Trieu K, Dunford E, HawkesC. Target Salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6:3274-87.. In Brazil, the agreed proportion of salt content reduction for the French roll was low, despite its high sodium density and high prevalence of consumption (it is the third type of food eaten the most in Brazil) ⁴4. de Moura Souza A, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. J Acad Nutr Diet 2013; 113:1359-65.^{), (17}17. de Moura Souza A, Pereira RA, Yokoo EM, Levy RB, Sichieri R. Alimentos mais consumidos no Brasil: Inquérito Nacional de Alimentação 2008-2009. Rev Saúde Pública 2013; 47 Suppl 1:190s-9s.. For the French roll, the total reduction was about 10%. However, a 55% reduction in the sodium content of this type of food, considering the lowest figure found in an American food composition table ¹⁸18. U.S. Department of Agriculture. Nutrient database for standard reference, release 18 (SR18). http://www.ars.usda.gov/research/publications (acessado em 20/Abr/2015).
http://www.ars.usda.gov/research/publica... , would lead to a 9% reduction in the mean salt intake (data not shown). Of note is the fact that food with low sodium density, but eaten more frequently, like rice and beans, are among those that contribute the most for the intake of sodium among the Brazilian population ⁴4. de Moura Souza A, Bezerra IN, Pereira RA, Peterson KE, Sichieri R. Dietary sources of sodium intake in Brazil in 2008-2009. J Acad Nutr Diet 2013; 113:1359-65.. Despite the contribution of processed foods to the mean sodium intake, the contribution of table salt and salt-based seasoning is noteworthy ⁶6. Sarno F, Claro RM, Levy RB, Bandoni DH, Monteiro CA. Estimativa de consumo de sódio pela população brasileira, 2008-2009. Rev Saúde Pública 2013; 47:571-8.. Therefore, in Brazil, it will be difficult to achieve the necessary sodium intake reduction with voluntary agreements like the ones that were made to date. Considering the increase of intake of ultraprocessed food, reviewing the targets or including other groups of foods will likely not suffice. For that, public policies that encourage behavioral changes towards reducing the use of salt in the preparation of food, and lower intake of ultraprocessed foods, based on the new Dietary Guidelines for the Brazilian Population¹⁹19. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014. play a crucial role in effectively changing sodium intake standards in the Brazilian population.

Acknowledgments

To Brazilian National Research Council (CNPq), Rio de Janeiro State Research Foundation (Faperj), and Brazilian Graduate Studies Coordinating Board (Capes).

References

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