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Dr. Gregory Weiss reviews a recent BMJ article detailing sodium content in processed meats and fish in different countries throughout the world and the implications it could have on cardiovascular health at a national level.
Cumulative salt intake has long been associated with cardiovascular health. Specifically, we know that there is a linear relationship between sodium intake and blood pressure which in turn increases the risk of cardiovascular morbidity and mortality.1 Armed with this information clinicians have long encouraged a low sodium diet especially in patients with other cardiovascular risk factors. One challenge is the lack of consistency in sodium content across a wide variety of foods. Meats and fish, especially when processed, have been identified as a source for high levels of sodium.2
The World Health Organization recommends a maximum daily sodium intake of 2000mg. In contrast to this goal the average global sodium intake exceeds 4000mg as of 2010.3 While the task of reducing overall sodium intake appears daunting steps have been taken globally to examine the sodium content in processed meats and fish in an effort to provide data that will allow us to target specific products to be avoided or modified to be less detrimental. To this end the George Institute for Global Health created the first global food composition database in 2010. The collection of food composition data from more than 10 countries has allowed the institute to compare sodium content in processed meats and fish on an unprecedented scale. Professor Yuxia Ma and colleagues in the Department of nutrition and food hygiene at Hebei Medical University in Shijiazhuang, China sought to compare sodium content and achievements in sodium reduction for different countries.
The group was able to examine over 30,000 processed meat and fish products. The following countries were identified from the highest sodium levels (China) to the lowest overall (Australia and the UK).2
While these rankings represent the overall sodium content in products examined, there were some variations between processed meat, fish and within specific categories of meats such as hot dogs and bacon.2
This comparison of sodium content in processed meat and fish products shows a wide discrepancy within and between countries. No wonder it is so difficult for clinicians to target education towards avoidance of certain products in an effort to reduce sodium intake and promote better cardiovascular health. While some countries had lower levels of sodium all countries included fell short or WHO recommendations with only 10% of UK and USA products and less than 5% of Chinese processed meats and fish falling in what is considered the “green light” category of acceptable sodium content for a food.2 This underscores the magnitude of this problem as well as the utility of this study.
As clinicians, we need targets to reach with our patients. The first step in making a target is defining the problem which in this case is high sodium content in processed meat and fish. With guidance from the WHO as to how much sodium patients should consume, we must then define where the salt is coming from. The authors have shown that processed meat and fish from a variety of countries is responsible for a significant portion of sodium intake worldwide.2 We know where the salt is coming from, but what is the next step?
It would be a daunting task to replace or reformulate high sodium containing products already in existence. However, these data suggest that there is a wide range of sodium content in the same or similar products in different countries. The authors suggest that this is an opportunity for manufacturers to heed the increasing call from consumers for lower sodium products.2 Further, countries and municipalities can set sodium targets for processed foods which has been shown effective in the handful of cases this has been tried. While concern for consumer driven flavor demands have been cited as a reason for higher sodium contents, it is possible that these concerns are unfounded.2
We can see through this investigation that there are many layers to the problem of sodium consumption and cardiovascular disease. Even though much variability exists from product to product and country to country we see that even more diligent countries like the UK have sodium contents per 100 grams of processed meat and fish that constitute up to one-half of the WHO maximum sodium intake for an entire day. We can and must do better. The authors believe that we must set feasible sodium lowering targets with regular re-evaluation aimed at ensuring adequate implementation. Consumers are better educated than ever before. Efforts must be made by clinicians to provide information, encourage meaningful behavior and nutritional changes, while working on the policy changes aimed at reducing the sodium content of the foods our patients eat.