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Reducing Salt in Foods

Reducing Salt in Foods

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Reducing Salt in Foods

628 pages
6 hours
Jun 18, 2019


Reducing Salt in Foods, Second Edition, presents updated strategies for reducing salt intake. The book contains comprehensive information on a wide range of topics, including the key health issues driving efforts to reduce salt, government action regarding salt reduction and the implications of salt labeling. Consumer perceptions of salt and views on salt reduction in different countries are also discussed, as are taste, processing and preservation functions of salt and salt reduction strategies. Final sections discuss salt reduction in particular food groups, including meat and poultry, seafood, bread, snack foods, dairy products and canned foods, each one including a case study.

This updated edition also includes a new section on the future of salt reduction, the development of new ingredients to replace salt, salt reduction in catering, and how to teach new generations to adjust salt levels from an early age.

  • Completely revised and updated with an overview of the latest developments in salt reduction
  • Presents guidelines to help with reducing salt in specific product groups
  • Presents a new section on the future of salt reduction, development of new ingredients to replace salt, salt reduction in catering and how to teach new generations to adjust salt levels from an early age
  • Contains new chapters on preservation issues, taste issues and processing issues when reducing salt in food, along with case studies that illustrate salt reduction
Jun 18, 2019

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Reducing Salt in Foods - Elsevier Science

Reducing Salt in Foods

Second Edition

Cindy Beeren

Kathy Groves

Pretima M. Titoria

Table of Contents

Cover image

Title page


About the editors

Part One: Dietary salt, health and the consumer

1: Salt and health


1.1 Introduction

1.2 Definition of hypertension

1.3 Benefits of lowering blood pressure in the ‘normal range’

1.4 Salt and blood pressure

1.5 Salt and cardiovascular disease

1.6 Other harmful effects of salt on health

1.7 Salt and other dietary and lifestyle changes for lowering blood pressure

1.8 Conclusions and perspectives

2: Dietary salt and flavour: mechanisms of taste perception and physiological controls


2.1 Introduction: Overview of perception and intake of sodium chloride

2.2 Transduction of sodium by taste receptor cells

2.3 Brain areas activated by salty taste

2.4 Physiological factors that influence salt intake

2.5 Implications for food product development

2.6 Future trends

2.7 Sources of further information and advice

3: Dietary salt: Consumption, reduction strategies and consumer awareness


3.1 Introduction

3.2 Dietary salt consumption

3.3 Reducing salt intake at a population level

3.4 National salt reduction programmes

3.5 Consumer awareness of dietary salt intake

3.6 Key conclusions

4: Impact of reduced salt products in the market place


4.1 Introduction: The importance of salt/sodium reduction in the minds of consumers

4.2 Overt reduction strategies in the global market

4.3 Covert reduction strategies in the market

4.4 Conclusions on the impact of reduced salt products in the market

Part Two: Strategies and implications for salt reduction in food products

5: Alternative ingredients to sodium chloride


5.1 Reducing sodium with alternative ingredients

5.2 Practical approach to sodium reduction

5.3 The decision process

5.4 Ingredient application—Examples/case studies

5.5 Conclusion

6: Microbial issues in salt reduction


6.1 Introduction

6.2 Replacement of salt with other compounds used to increase osmotic pressure

6.3 Methods to reduce salt without compromising microbial safety

6.4 Techniques to assess the effect of salt reduction on the safety and quality of food

6.5 Conclusions

6.6 Future trends

Part Three: Reducing salt in particular foods

7: Reducing salt in meat and poultry products


7.1 Introduction

7.2 Functions of NaCl in meat and poultry products

7.3 Sodium content in meat and poultry products

7.4 Strategies for NaCl reduction in meat and poultry products

7.5 Conclusions and future trends

8: Reducing salt levels in seafood products



8.1 Introduction

8.2 Consumption of seafood products

8.3 Technological functions of salt in seafood

8.4 Current levels of salt in seafood

8.5 Strategies for lowering salt content in seafood

8.6 Recommendations

9: Reduced salt and sodium in bread and other baked products


9.1 Introduction

9.2 The technological functions of salt in the processing of baked products

9.3 Other sodium salts in baked products

9.4 Levels of salt in baked products

9.5 Methods for reducing salt and sodium levels while retaining quality and safety

9.6 Future trends

Sources of further information and advice

10: Breakfast cereals



10.1 Breakfast cereals

10.2 Breakfast cereals market size

10.3 Types of breakfast cereals

10.4 Sodium and breakfast cereals

10.5 Sources and functional role of sodium in breakfast cereals

10.6 Sources and functional role of non-sodium alternatives for breakfast cereals

10.7 Conclusions

11: Breakfast spreads


11.1 Breakfast spreads

11.2 Sodium content of breakfast spreads

11.3 Sodium-containing ingredients in breakfast spreads

11.4 Non-sodium alternative for breakfast goods

11.5 Conclusions

12: Sauces and seasonings


12.1 Introduction

12.2 Salt in seasonings and sauces

12.3 Strategies for reducing salt in seasonings and sauces

12.4 Conclusion



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About the editors

Cindy Beeren has worked for 20 years in the Sensory, Consumer, & Taste areas. Salt and Sugar Reduction has been a focus of her work for more than 10 years. Cindy currently heads up the operational areas at Leatherhead Food Research and one of its sister companies. She is also the past Chair of the UK's Sensory Science Group, and closely involved with the global sensory science community.

Kathy Groves has more than 40 years of experience in food microstructure and its relationship to product texture, processing properties, and stability. She is a Fellow of the Royal Microscopical Society and of the Institute of Food Science & Technology and is visiting Professor at the University of Chester, UK. Kathy is currently a Director of Foodview Ltd.

Dr. Pretima Titoria has more than 25 years of experience in the food industry, focusing on the behaviour of ingredients and hydrocolloids, and correlating their functionalities to textural/rheological and microstructural behaviours within different food & beverage and nonfood applications. Pretima works at Leatherhead Food Research, UK, and is a Fellow of the Institute of Food Science & Technology.

Part One

Dietary salt, health and the consumer


Salt and health

Feng J. He; Monique Tan; Graham A. MacGregor    Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom


Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. The most important risk factor for cardiovascular disease is raised blood pressure. Salt intake is the major cause of raised blood pressure, as demonstrated by several different lines of evidence – epidemiological, migration, population-based intervention, treatment, animal, and genetic studies. Independently and additive to its effects on blood pressure, the current high-salt intake (9–12 g per day in most countries of the world) also has a direct effect on stroke, left ventricular hypertrophy, renal disease, stomach cancer, and bone demineralization. Reducing our salt intake to the recommended 5–6 g per day will result in major public health gains; a further reduction to 3 g per day would have a much greater impact and should become the long-term target for population salt intake worldwide. As 75%–80% of the salt intake in developed countries comes from processed foods, the most effective strategy is for the food industry to reduce the amount of salt added to their products in a gradual and sustained manner. Several developed countries (e.g. Finland, the United Kingdom) have successfully reduced their population salt intake, and this was accompanied by significant falls in population blood pressure and CVD mortality. A major challenge now is to expand this to developing countries, where over 80% of the global salt-related disease burden occurs. A reduction in salt intake worldwide, even in small amounts, will result in enormous public health gains and cost savings.


Salt; Blood pressure; Health; Salt reduction; Public health

1.1 Introduction

The leading cause of death and disability worldwide is cardiovascular disease (strokes, heart attacks, and heart failure), and the major risk factor for cardiovascular disease is raised blood pressure (Forouzanfar et al., 2017; Lewington et al., 2002; Lim et al., 2012). Dietary salt (sodium chloride) is an important regulator of blood pressure, with several different lines of evidence – epidemiology (Elliott et al., 1996), migration (Poulter et al., 1990), population-based intervention (Forte et al., 1989), treatment (He and MacGregor, 2002), animal (Denton et al., 1995) and genetic studies (Lifton, 1996) – consistently showing that a reduction in salt intake leads to a reduction in population blood pressure and slows down the rise in blood pressure with age.

There is also increasing evidence that our current high-salt intake has other harmful effects on human health, independently and additively to its effect on blood pressure. For instance, evidence exists on a direct effect of salt on stroke (Perry and Beevers, 1992), left ventricular hypertrophy (Kupari et al., 1994; Schmieder and Messerli, 2000), progression of renal disease and albuminuria (Cianciaruso et al., 1998; He et al., 2009; Heeg et al., 1989; Swift et al., 2005), increasing the risk of stomach cancer (Joossens et al., 1996; Tsugane et al., 2004), and bone demineralization (Devine et al., 1995).

In view of this, the World Health Organization has set a global target of 30% reduction in salt intake by 2025, and recommends adults to reduce their salt intake to < 5 g per day (World Health Organization, 2013).

In this chapter, we will provide an update on the body of evidence that relates salt to blood pressure and cardiovascular disease. We will also discuss the evidence on other harmful effect of salt on health.

1.2 Definition of hypertension

The relationship between blood pressure and cardiovascular disease displays a continuous graded relationship starting at 115/75 mmHg, and there is no evidence of any threshold level of blood pressure below which lower levels of blood pressure are not associated with lower risks of cardiovascular disease (Lewington et al., 2002). Thus, any classification of people into categories (‘normotensive’ and ‘hypertensive’) is inherently arbitrary. Nevertheless, it is useful to provide a classification of blood pressure for the purpose of identifying high-risk individuals and providing guidelines for treatment and control.

Late Professor Geoffrey Rose suggested that ‘the operational definition of hypertension is the level at which the benefits ... of action exceed those of inaction’ (Rose, 1980). The criteria for the classification of hypertension have changed over the past 50 years as studies have shown benefit at lower levels of blood pressure (Vasan et al., 2001). The Seventh Joint National Committee (JNC VII) (Chobanian et al., 2003) defined individuals with blood pressure < 120/80 mmHg as ‘normal’ and those with blood pressure ≥ 140 mmHg systolic or ≥ 90 mmHg diastolic as ‘hypertension’. For for those with blood pressure ranging from 120 to 139 mmHg systolic and/or 80 to 89 mmHg diastolic, the JNC VII report has introduced a new term ‘prehypertension’. This new designation was intended to identify those individuals in whom early intervention by adoption of healthy lifestyles could reduce blood pressure, decrease the rate of progression of blood pressure to hypertensive levels with age, or prevent hypertension entirely.

Hypertension is extremely common in Western countries. For instance, in England, just under 30% of the entire adult population had hypertension (systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg) in 2016 (NatCen Social Research, 2017). The prevalence of hypertension increases with age, e.g. at the age of 55–64 years, 40.1% had high blood pressure, and at the age of 65–74 years, 58.0% had high blood pressure (Health and Social Care Information Centre, 2017). Many treatment trials have demonstrated a clear benefit of lowering blood pressure in hypertensive individuals (Staessen et al., 2001).

1.3 Benefits of lowering blood pressure in the ‘normal range’

In the general population, blood pressure is distributed in a roughly normal or Gaussian manner (i.e. bell-shaped curve) with a slight skew towards higher readings. Although the risk of cardiovascular mortality increases progressively with increases in blood pressure, for the population at large, the greatest number of strokes, heart attacks, and heart failure attributable to blood pressure occurs in the upper range of normal blood pressure (i.e. systolic between 130 and 140 mmHg and diastolic between 80 and 90 mmHg) because there are so many individuals who have blood pressure at these levels in the population (Rodgers et al., 2004). Therefore, a population-based approach aimed at achieving a downward shift in the distribution of blood pressure in the whole population, even by a small amount, will have a large impact on reducing the number of strokes, heart attacks, and heart failure.

1.4 Salt and blood pressure

1.4.1 Evidence that relates salt to blood pressure

The earliest comment that relates dietary salt to blood pressure was recorded in the ancient Chinese medical literature – the Yellow Emperor’s classic on internal medicine, Huang Ti Nei Ching Su Wein, 2698–2598 BCE. It is stated that ‘If too much salt is used for food, the pulse hardens …’. However, the first meaningful scientific evidence for a link between salt intake and blood pressure only emerged in the early 1900’s. There is now overwhelming evidence for a causal relationship between salt intake and blood pressure. The evidence comes from the following sources:

●Epidemiological studies

●Migration studies

●Population-based intervention studies

●Treatment trials

●Animal studies

●Genetic studies Epidemiological studies

In 1960, Dahl reported a strong relationship between average-salt intake and prevalence of hypertension in an ecological study of five geographically diverse populations (Dahl, 1960). Subsequently, several other authors have confirmed Dahl’s findings. The limitations of these across-population studies are that the data were from several different studies that used unstandardised methods, and few collected data on potential confounding factors. The multiple social and environmental differences among populations around the world may affect the salt-blood pressure relationship.

Within-population studies have been hampered by a number of methodological challenges including measurement difficulties caused by large variations in day-to-day salt intake within and between individuals, as well as a wide range of blood pressure values for a given level of salt intake due to the multifactorial nature of environmental and genetic influence on blood pressure. As such, a large number of individuals would be required to demonstrate a significant association between habitual salt intake and blood pressure. The large international study – INTERSALT (INTERSALT, 1988), which involved 10,079 individuals from 52 centres around the world using standardised methods of measuring blood pressure and 24-h urinary sodium, demonstrates that salt intake is an important factor in determining population blood pressure level and the rise in blood pressure with age (Fig. 1.1). It was estimated that an increase of 6 g/day in salt intake is related to a rise of 10/6 mmHg in blood pressure over 30 years (e.g. from age of 25 to 55 years), which represents a large increase in population blood pressure.

Fig. 1.1 The relationship between salt intake and the slope of the rise in systolic blood pressure with age in 52 centres in the INTERSALT study. Modified from INTERSALT, 1988. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt cooperative research group. BMJ 297, 319–28.

Many of the INTERSALT investigators have collaborated in another major nutrition-blood pressure study, the INTERMAP study, which shed additional light on the salt-blood pressure relationship. One article from the INTERMAP group reports nutrient intakes in 4 countries: China, Japan, UK, and USA (Zhou et al., 2003). The results confirm the findings from INTERSALT that China and Japan, where hypertension prevalence and stroke mortality are very high, have a higher salt intake, lower potassium intake, and therefore, a higher salt/potassium ratio, compared with the UK and the USA.

In the INTERSALT study, only 4 communities had a salt intake < 3 g/day. A number of other studies have studied the nonacculturated tribes, which have a low-salt intake (< 3 g/day). Individuals in these tribes have lower levels of blood pressure and, more importantly, their blood pressure does not rise with age. The most striking example is the Yanomamo Indians on the border between Venezuela and Brazil (Mancilha-Carvalho et al., 1989; Oliver et al., 1975). They have a salt intake of 0.05 g/day. The average blood pressure for adults is only 96/61 mmHg, and there is no rise in blood pressure with age and no evidence of cardiovascular disease. Whilst there may be other factors that also account for the lower blood pressure, several studies have clearly demonstrated the profound importance of salt. A study in the Pacific Islands where one undeveloped community used salt water in their food and the other did not, showed that the community using salt had higher blood pressure (Page et al., 1974). Another study in Nigeria of two rural communities, one of which had access to salt from a salt lake and the other did not, showed differences in salt intake and differences in blood pressure, and yet in all other aspects of lifestyle and diet the two communities were similar. The Qash’qai, an undeveloped tribe living in Iran who have access to salt deposits on the ground, develop high blood pressure and a rise in blood pressure with age similar to that which occurs in Western communities, but they live a lifestyle similar to nonacculturated societies (Page et al., 1981). Migration studies

A number of studies have shown that migration from isolated societies with low salt intakes to Westernised environment with a high-salt intake is associated with an increase in blood pressure, a rise in blood pressure with age, and a higher prevalence of hypertension. For instance, a well-controlled migration study of a rural tribe in Kenya showed that upon migration to an urban environment, there was an increase in salt intake and a reduction in potassium intake, and blood pressure rose after a few months, compared to those in the control group who remained in the rural environment (Poulter et al., 1990).

Another example of migration study is that of the Yi people, an ethnic minority living in southwestern China (He et al., 1991a,b). Blood pressure rose very little with increasing age (0.13/0.23 mmHg/year) in the Yi farmers who lived in their natural remote mountainous environment and consumed a low-salt diet. In contrast, Yi migrants and Han people who lived in urban areas consumed a high-salt diet and experienced a much greater increase in blood pressure with increasing age (0.33/0.33 mmHg/year) (He et al., 1991a). In a sample of 417 recent migrants (Yi) or native (Han) men living in the urban areas, there was a significant positive relationship between salt intake and blood pressure. These findings suggest that changes in lifestyle, including higher salt intake, contribute to the higher blood pressure among Yi migrants (He et al., 1991b). Population-based intervention studies

In the late 1950s, the Japanese became aware that certain parts of Japan, particularly in the north, had a high-salt consumption and deaths from stroke were among the highest in the world. It was then found that the number of strokes in different parts of Japan was directly related to the levels of salt intake. In view of these findings, there was a government-led campaign to reduce salt intake, which was successful in reducing salt intake over the following decade from an average of 13.5 g per day to 12.1 g per day. In northern Japan, salt intake fell from 18 g per day to 14 g per day. This resulted in a gradual fall in blood pressure both in adults and children, and an 80% reduction in stroke mortality (Iso et al., 1999; Kimura, 1983; Tanaka et al., 1982).

Several population-based well-controlled intervention studies have been carried out. One was conducted in two similar villages in Portugal (Forte et al., 1989). Each village had approximately 800 inhabitants who had salt intakes of 21 g per day and the prevalence of hypertension and stroke mortality was very high. During the two-year intervention period, there was a vigorous, widespread health education effort to reduce salt intake especially from those foods that had previously been identified as the major sources of salt in the intervention village. No dietary advice was given in the control village. The intervention was successful in achieving a difference of approximately 50% in salt intake between the two villages. This caused a significant difference in blood pressure at 1 year and a more pronounced difference at 2 years (a difference of 13/6 mmHg in blood pressure between the two villages) (Fig. 1.2).

Fig. 1.2 Blood pressure changes with time in two Portuguese villages, one of which had salt intake reduced, the other had similar measurements of blood pressure but no advice on diet. Note the significant differences in blood pressure at 1 year and continuing differences at 2 years. Adapted from Forte, J.G., Miguel, J.M., Miguel, M.J., de Padua, F., Rose, G., 1989. Salt and blood pressure: a community trial. J. Hum. Hypertens. 3, 179–84.

Another population-based intervention study was carried out in Tianjin, China, where the salt intake as well as the prevalence of hypertension and stroke mortality were also very high. The intervention was evaluated based on examinations of independent cross-sectional population samples in 1989 (1719 persons) and 1992 (2304 persons) (Tian et al., 1995). During the intervention period, there was a small reduction in salt intake in the intervention area, whereas in the control area there was a small increase in salt intake, so that the net difference in the change in salt intake between the intervention and control area was 2.4 g per day in men and 0.9 g per day in women. This was associated with a difference in systolic blood pressure of 5 mmHg in men and 4 mmHg in women.

These population-based intervention studies clearly demonstrate that a reduction in population salt intake lowers population blood pressure. A reduction in population blood pressure, even by a small amount, will have a large impact on reducing cardiovascular morbidity and mortality.

Two other intervention studies (one in Belgium, and the other in North Karelia) are often quoted as being negative (Staessen et al., 1988; Tuomilehto et al., 1984). However, neither were successful in reducing salt intake and it is not surprising that there was no difference in blood pressure in these studies between the community that was instructed on reducing salt, but failed to do so, and the community that was not given such instructions. Treatment trials

Ambard and Beaujard were the first to show that reducing salt intake lowered blood pressure in 1904. These results were confirmed over the next 30 years by several researchers, but it was not until Kempner (1948) resuscitated the idea of a large reduction in salt intake that salt restriction became widely used in the treatment of hypertension. The first double-blind placebo-controlled trial of a more modest reduction in salt intake was performed in the 1980s in a group of untreated patients with essential hypertension (MacGregor et al., 1982). It clearly demonstrated that a reduction in salt intake from 10 to 5 g/day for one month caused a significant fall in blood pressure, which was equivalent to that seen with a diuretic. Since then, a large number of salt reduction trials have been carried out not only in hypertensive individuals, but also in normotensive subjects.

Several meta-analyses of salt reduction trials have been performed (Cutler et al., 1997; Graudal et al., 1998; Hooper et al., 2002; Law et al., 1991; Midgley et al., 1996). In a series of meta-analyses – the latest of which recently updated in the Cochrane Library (Graudal et al., 2017) – it was claimed that salt reduction had no or very little effect on blood pressure in normotensive individuals, leading their authors to conclude that a reduction in population salt intake is not warranted. These papers cast doubt on the link between salt intake and blood pressure and have been used to oppose the public health recommendation of reducing salt intake. However, detailed examination of these meta-analyses shows that they are flawed. Not only were trials of very short duration included – many lasting for only 5 days – but also trials comparing the effects of acute salt loading to abrupt and severe salt restriction, e.g. from 20 to < 1 g/day of salt for only a few days. It is known that these acute and large changes in salt intake cause an increase in sympathetic activity, plasma renin activity, and angiotensin II concentration (He et al., 2001b), which would counteract the effects on blood pressure. It is also known that most blood pressure-lowering drugs do not exert their maximal effect within 5 days; this is particularly true with diuretics, which are likely to work by a similar mechanism to that of a reduction in salt intake. For these reasons, it is inappropriate to include the acute salt restriction trials in a meta-analysis that attempts to apply them to public health recommendations for a longer-term modest reduction in salt intake.

A meta-analysis by Hooper et al. (2002) is an important attempt to look at whether long-term salt reduction (i.e. > 6 months) in randomised trials causes a fall in blood pressure. However, most trials included in this meta-analysis only achieved a very small reduction in salt intake and, on average, salt intake was only reduced by 2 g/day. It is, therefore, not surprising that there was only a small, but still highly significant fall in blood pressure.

More recently, two meta-analyses were carried out on randomised trials of longer-term modest salt reduction (Aburto et al., 2013; He et al., 2013). Both demonstrated that a modest reduction in salt intake, as currently recommended, does have a significant effect on blood pressure not only in hypertensive individuals, but also in those with normal blood pressure (Fig. 1.3). Furthermore, a dose-response relationship to salt reduction was demonstrated within the range of 12 to 3 g/day, i.e. the lower the salt intake, the lower the blood pressure (He et al., 2013).

Fig. 1.3 Effect of modest salt reduction on blood pressure in hypertensive and normotensive individuals in a meta-analysis of 34 randomised controlled trials of 1 month or longer. Adapted from He, F.J., Li, J., MacGregor, G.A., 2013. Effect of longer term modest salt reduction on blood pressure: cochrane systematic review and meta-analysis of randomised trials. BMJ 346, f1325. doi:10.1136/bmj.f1325.

Randomised trials also show that, for a given reduction in salt intake, the falls in blood pressure are larger in individuals of African origin, in older people, and in hypertensive individuals, compared with individuals of Caucasian origin, young people, and normotensive individuals, respectively (Sacks et al., 2001). The greater falls in blood pressure with salt reduction are related to lower levels of plasma renin activity and, thereby, angiotensin II, as well as the less responsiveness of the renin-angiotensin system in these individuals (He et al., 1998).

A modest reduction in salt intake is also additive to antihypertensive drug treatments (MacGregor et al., 1987). Longer-term trials have shown that salt reduction enhances blood pressure control and reduces the need for antihypertensive drug therapy (Whelton et al., 1998). Salt reduction in children

Salt intake matters from a young age. A meta-analysis of three controlled trials with 551 infants showed that with a 54% reduction in salt intake lasting for an average of 20 weeks, systolic blood pressure was reduced by 2 mmHg. Of the three trials included in this meta-analysis, two were conducted in the early 1970s and 1980s: at that time, formula milks contained approximately three times more salt than human milk. Nowadays, in most developed countries, salt is no longer added to formula milk or baby foods, bringing the salt concentrations in formula milk down to the level of human milk. However, once table foods are introduced at about 6 to 9 months of age, salt intake in infants and toddlers is dramatically increased, and even more so at about 12 months, when cow’s milk is introduced. In a study conducted in the United States, the salt intake of 12- to 24-month-old toddlers averaged at 4.1 g per day, exceeding the ‘adequate level’ of the Dietary Reference Intake – established by the Food and Nutrition Board of the Institute of Medicine – in almost all toddlers (Heird et al., 2006). Such intake levels are obviously far too high and reducing those toddlers’ salt intake would be beneficial for their blood pressure.

Salt intake in early life may have a long-lasting effect on blood pressure. A well-controlled double-blind study in just under 500 newborn babies showed that when salt intake was reduced by about half (intervention vs. control group) for 6 months, as judged by spot urinary sodium concentrations, there was a progressive difference in systolic blood pressure (Hofman et al., 1983). At the end of 6 months, the babies on the lower salt intake had a 2.1-mmHg lower systolic blood pressure (P < 0.01) (Fig. 1.4). The study was discontinued at 6 months. Fifteen years later, 35% of these babies were restudied. There remained a significant difference in blood pressure, when adjusted for confounding factors, between those babies who in the first 6 months of life had had a reduced salt intake compared to those who had not (Geleijnse et al., 1997). This study suggests that there was a programming effect of salt intake in early life, which fits with several studies in animals (Dahl et al., 1968).

Fig. 1.4 Difference in systolic blood pressure in newborn babies, randomised to either a normal salt intake or a reduced salt intake over the first 6 months of life. At 6 months, the study was discontinued, with all participants resuming their usual salt intake. Fifteen years later, a subgroup of those in the study had blood pressure re-measured. Adapted from Geleijnse, J.M., Hofman, A., Witteman, J.C., Hazebroek, A.A., Valkenburg, H.A., Grobbee, D.E., 1997. Long-term effects of neonatal sodium restriction on blood pressure. Hypertension 29, 913–7; Hofman, A., Hazebroek, A., Valkenburg, H.A., 1983. A randomized trial of sodium intake and blood pressure in newborn infants. JAMA 250, 370–3.

Some observational studies included multiple measurements of salt intake, measurement of urinary sodium, and control for confounding factors. Of these, most showed a significant positive association between salt intake and blood pressure (He et al., 2008a; Simons-Morton and Obarzanek, 1997). An example is a carefully conducted study on 73 children aged 11 to 14 years, where seven consecutive 24-h urine samples were collected. There was a significant linear relationship between urinary sodium and systolic blood pressure, which remained significant after accounting for age, sex, ethnicity, pulse rate, height, and body weight (Cooper et al., 1980).

A number of studies have looked at the effect of reducing dietary salt intake on blood pressure in children. However, most of these studies either did not achieve any reduction in salt intake, or were underpowered to detect a small fall in blood pressure with reducing salt intake in children. A meta-analysis of 10 salt reduction trials with a total of 966 children and adolescents showed that a modest reduction in salt intake had a significant effect on blood pressure, i.e. a 42% reduction in salt intake, lasting for an average of four weeks, led to a 1.2-mmHg decrease in systolic blood pressure and a 1.3-mmHg decrease in diastolic blood pressure (He and MacGregor, 2006). A more recent meta-analysis confirmed the relationship between salt intake and blood pressure in children and adolescents (Leyvraz et al., 2018).

The crucial public health importance of controlling children’s salt intake is further highlighted by the fact that patterns of blood pressure in childhood reflect those in adulthood: the higher the blood pressure during childhood, the higher the blood pressure in adulthood (Lauer and Clarke, 1989). This implies that a lower-salt diet starting from childhood could lessen the subsequent rise in blood pressure with age, which would have major public health implications in preventing the development of hypertension and cardiovascular disease later in life.

Currently, salt intake in children is very high. In 1984, at a time when consumption of processed foods by children was not high, a study in the United Kingdom where 2 consecutive 24-h urine samples were collected in 34 pupils aged 4 to 5 years showed a salt intake of 4 g of salt per day (Courcy et al., 1986). Expressed for adults on a weight basis, this would equate to an intake of approximately 15 to 20 g/day. Since then, children’s salt intake has increased due to the rising consumption of processed foods, which currently account for approximately 80% of the total salt intake in developed countries. In the United States, surveys showed that the proportion of foods consumed by children in restaurants and fast-food outlets increased by nearly 300% between 1977 and 1996 (St-Onge et al., 2003) and this trend has most likely continued in more recent years, alongside the consumption of snack food. Processed, restaurant, fast foods and snacks usually contain very high amounts of salt, fat, and sugar. It is possible that children from the age of 3 onwards now consume as much salt as adults. Animal studies

There are numerous studies in the rat, dog, chicken, rabbit, baboon and chimpanzee, all of which have shown that when there is a prolonged increase in salt intake there is an increase in blood pressure (Denton et al., 1995; Elliott et al., 2007). Furthermore, in all forms of experimental hypertension, whatever the animal model, a high-salt intake is essential for blood pressure to rise.

A study was carried out in chimpanzees (98.8% genetic homology with man) (Denton et al., 1995). In a randomised parallel study, one group of chimpanzees was maintained on their normal diet of around half a gram of salt per day (N = 12), and the other had their salt intake increased to 5, 10 and 15 g/day (N = 10). During the study there was no significant change in blood pressure in the control group. However, in the 10 chimpanzees assigned to the increased salt intake, mean systolic blood pressure was increased by 12 mmHg compared to the corresponding baseline level (P < .05) after the first 19 weeks of supplementary salt intake (5 g/day). Following the 39 weeks of supplementation with 10 g/day of salt (3 weeks) and 15 g/day of salt (36 weeks), mean systolic blood pressure was increased by 26 mmHg (P < .001). Following a further 26 weeks of supplementation with 15 g/day of salt (a total of 84 weeks of supplementation with salt), mean systolic was increased by 33 mmHg (P < .001). Twenty weeks after the end of the salt supplementation period, the animals’ average level of blood pressure returned to its baseline level (Fig. 1.5). This experiment provides a direct evidence for a causal relationship

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