IDEAS home Printed from https://ideas.repec.org/a/plo/pone00/0177535.html
   My bibliography  Save this article

Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy?

Author

Listed:
  • Lirije Hyseni
  • Alex Elliot-Green
  • Ffion Lloyd-Williams
  • Chris Kypridemos
  • Martin O’Flaherty
  • Rory McGill
  • Lois Orton
  • Helen Bromley
  • Francesco P Cappuccio
  • Simon Capewell

Abstract

Background: Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared “downstream, agentic” approaches targeting individuals with “upstream, structural” policy-based population strategies. Methods: We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from “downstream”: dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most “upstream” regulatory and fiscal interventions, and comprehensive strategies involving multiple components. Results: After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals. Conclusions: Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and “upstream” population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than “downstream”, individually focussed interventions. This ‘effectiveness hierarchy’ might deserve greater emphasis in future NCD prevention strategies.

Suggested Citation

  • Lirije Hyseni & Alex Elliot-Green & Ffion Lloyd-Williams & Chris Kypridemos & Martin O’Flaherty & Rory McGill & Lois Orton & Helen Bromley & Francesco P Cappuccio & Simon Capewell, 2017. "Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy?," PLOS ONE, Public Library of Science, vol. 12(5), pages 1-35, May.
  • Handle: RePEc:plo:pone00:0177535
    DOI: 10.1371/journal.pone.0177535
    as

    Download full text from publisher

    File URL: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0177535
    Download Restriction: no

    File URL: https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0177535&type=printable
    Download Restriction: no

    File URL: https://libkey.io/10.1371/journal.pone.0177535?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    References listed on IDEAS

    as
    1. Helen Mason & Azza Shoaibi & Rula Ghandour & Martin O'Flaherty & Simon Capewell & Rana Khatib & Samer Jabr & Belgin Unal & Kaan Sözmen & Chokri Arfa & Wafa Aissi & Habiba Ben Romdhane & Fouad Fouad & , 2014. "A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries," PLOS ONE, Public Library of Science, vol. 9(1), pages 1-10, January.
    2. Kathy Trieu & Bruce Neal & Corinna Hawkes & Elizabeth Dunford & Norm Campbell & Rodrigo Rodriguez-Fernandez & Branka Legetic & Lindsay McLaren & Amanda Barberio & Jacqui Webster, 2015. "Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target," PLOS ONE, Public Library of Science, vol. 10(7), pages 1-22, July.
    3. Bhavani Shankar & Jose Brambila‐Macias & Bruce Traill & Mario Mazzocchi & Sara Capacci, 2013. "An Evaluation Of The Uk Food Standards Agency'S Salt Campaign," Health Economics, John Wiley & Sons, Ltd., vol. 22(2), pages 243-250, February.
    4. Linda J Cobiac & Anne Magnus & Stephen Lim & Jan J Barendregt & Rob Carter & Theo Vos, 2012. "Which Interventions Offer Best Value for Money in Primary Prevention of Cardiovascular Disease?," PLOS ONE, Public Library of Science, vol. 7(7), pages 1-10, July.
    5. Jean Adams & Oliver Mytton & Martin White & Pablo Monsivais, 2016. "Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency," PLOS Medicine, Public Library of Science, vol. 13(4), pages 1-7, April.
    6. Simon Capewell & Hilary Graham, 2010. "Will Cardiovascular Disease Prevention Widen Health Inequalities?," PLOS Medicine, Public Library of Science, vol. 7(8), pages 1-5, August.
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Nhung Nghiem & Tony Blakely & Linda J Cobiac & Amber L Pearson & Nick Wilson, 2015. "Health and Economic Impacts of Eight Different Dietary Salt Reduction Interventions," PLOS ONE, Public Library of Science, vol. 10(4), pages 1-18, April.
    2. Nicole E. H. Stappers & Dave H. H. Van Kann & Nanne K. De Vries & Stef P. J. Kremers, 2018. "Do Physical Activity Friendly Neighborhoods Affect Community Members Equally? A Cross-Sectional Study," IJERPH, MDPI, vol. 15(6), pages 1-13, May.
    3. Harvey-Sullivan, Adam & Lynch, Heidi & Tolley, Abraham & Gitlin-Leigh, Guy & Kuhn, Isla & Ford, John Alexander, 2024. "What impact do self-referral and direct access pathways for patients have on health inequalities?," Health Policy, Elsevier, vol. 139(C).
    4. Silvia F Hope & Jacqui Webster & Kathy Trieu & Arti Pillay & Merina Ieremia & Colin Bell & Wendy Snowdon & Bruce Neal & Marj Moodie, 2017. "A systematic review of economic evaluations of population-based sodium reduction interventions," PLOS ONE, Public Library of Science, vol. 12(3), pages 1-22, March.
    5. Livio Garattini & Giovanni Fattore, 2025. "Obesity epidemic in European countries: from an unaddressed risk factor to a medicalized disease?," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 26(1), pages 1-5, February.
    6. Sarah Gerritsen & Sophia Harré & Boyd Swinburn & David Rees & Ana Renker-Darby & Ann E. Bartos & Wilma E. Waterlander, 2019. "Systemic Barriers and Equitable Interventions to Improve Vegetable and Fruit Intake in Children: Interviews with National Food System Actors," IJERPH, MDPI, vol. 16(8), pages 1-19, April.
    7. Madhavi Bajekal & Shaun Scholes & Martin O’Flaherty & Rosalind Raine & Paul Norman & Simon Capewell, 2013. "Unequal Trends in Coronary Heart Disease Mortality by Socioeconomic Circumstances, England 1982–2006: An Analytical Study," PLOS ONE, Public Library of Science, vol. 8(3), pages 1-15, March.
    8. Silva, Andres & Etilé, Fabrice & Boizot-Szantai, Christine & Dharmasena, Senarath, 2013. "The Impact of Beverage Taxes on Quantity and Quality of Consumption in France," 2013 Annual Meeting, August 4-6, 2013, Washington, D.C. 150428, Agricultural and Applied Economics Association.
    9. Sharea Ijaz & James Nobles & Laura Johnson & Theresa Moore & Jelena Savović & Russell Jago, 2021. "Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective," IJERPH, MDPI, vol. 18(24), pages 1-25, December.
    10. Gesa Czwikla & Filip Boen & Derek G. Cook & Johan de Jong & Tess Harris & Lisa K. Hilz & Steve Iliffe & Richard Morris & Saskia Muellmann & Denise A. Peels & Claudia R. Pischke & Benjamin Schüz & Mart, 2019. "Equity-Specific Effects of Interventions to Promote Physical Activity among Middle-Aged and Older Adults: Development of a Collaborative Equity-Specific Re-Analysis Strategy," IJERPH, MDPI, vol. 16(17), pages 1-17, September.
    11. Ding Ding & Anna Do & Heather-Marie Schmidt & Adrian E Bauman, 2015. "A Widening Gap? Changes in Multiple Lifestyle Risk Behaviours by Socioeconomic Status in New South Wales, Australia, 2002–2012," PLOS ONE, Public Library of Science, vol. 10(8), pages 1-13, August.
    12. Tarra L. Penney & Thomas Burgoine & Pablo Monsivais, 2018. "Relative Density of Away from Home Food Establishments and Food Spend for 24,047 Households in England: A Cross-Sectional Study," IJERPH, MDPI, vol. 15(12), pages 1-13, December.
    13. Di Vita, Giuseppe & D'amico, Mario & Lombardi, Alessia & Pecorino, Biagio, 2016. "Evaluating trends of low sodium content in food: The willingness to pay for salt-reduced bread, a case study," Agricultural Economics Review, Greek Association of Agricultural Economists, vol. 17(2), June.
    14. Thomas Burgoine & Joreintje D. Mackenbach & Jeroen Lakerveld & Nita G. Forouhi & Simon J. Griffin & Søren Brage & Nicholas J. Wareham & Pablo Monsivais, 2017. "Interplay of Socioeconomic Status and Supermarket Distance Is Associated with Excess Obesity Risk: A UK Cross-Sectional Study," IJERPH, MDPI, vol. 14(11), pages 1-13, October.
    15. Rachel Griffith & Martin O'Connell & Kate Smith, 2017. "The Importance of Product Reformulation Versus Consumer Choice in Improving Diet Quality," Economica, London School of Economics and Political Science, vol. 84(333), pages 34-53, January.
    16. Chris Kypridemos & Piotr Bandosz & Graeme L Hickey & Maria Guzman-Castillo & Kirk Allen & Iain Buchan & Simon Capewell & Martin O’Flaherty, 2015. "Quantifying the Contribution of Statins to the Decline in Population Mean Cholesterol by Socioeconomic Group in England 1991 - 2012: A Modelling Study," PLOS ONE, Public Library of Science, vol. 10(4), pages 1-18, April.
    17. Irz, Xavier & Jensen, Jørgen Dejgaard & Leroy, Pascal & Réquillart, Vincent & Soler, Louis-Georges, 2017. "A Cross-Country Comparison of the Sustainability Effects of Dietary Recommendations," 2017 International Congress, August 28-September 1, 2017, Parma, Italy 261114, European Association of Agricultural Economists.
    18. Réquillart, Vincent & Soler, Louis-Georges & Zang, Yu, 2016. "Quality standards versus nutritional taxes: Health and welfare impacts with strategic firms," Journal of Health Economics, Elsevier, vol. 50(C), pages 268-285.
    19. Castiglione, Concetta & Mazzocchi, Mario, 2019. "Ten years of five-a-day policy in the UK: Nutritional outcomes and environmental effects," Ecological Economics, Elsevier, vol. 157(C), pages 185-194.
    20. Irz, Xavier & Leroy, Pascal & Réquillart, Vincent & Soler, Louis-Georges, 2016. "Welfare and sustainability effects of dietary recommendations," Ecological Economics, Elsevier, vol. 130(C), pages 139-155.

    More about this item

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:plo:pone00:0177535. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: plosone (email available below). General contact details of provider: https://journals.plos.org/plosone/ .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.