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Research

The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction

Elizabeth Dunford, Jacqueline Webster, Mark Woodward, Sebastien Czernichow, Wen Lun Yuan, Katharine Jenner, Cliona Ni Mhurchu, Michael Jacobson, Norm Campbell and Bruce Neal
CMAJ June 12, 2012 184 (9) 1023-1028; DOI: https://doi.org/10.1503/cmaj.111895
Elizabeth Dunford
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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  • For correspondence: edunford@georgeinstitute.org.au
Jacqueline Webster
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Mark Woodward
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Sebastien Czernichow
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Wen Lun Yuan
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Katharine Jenner
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Cliona Ni Mhurchu
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Michael Jacobson
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Norm Campbell
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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Bruce Neal
From The George Institute for Global Health (Dunford, Webster, Woodward, Neal), The University of Sydney (Dunford, Neal), Sydney, Australia; the Department of Nutrition, University Versailles St-Quentin and A. Paré Hospital, Boulogne-Billancourt, France (Czernichow); the Department of Epidemiology (Yuan), McGill University, Montréal, Que.; Wolfson Institute of Preventive Medicine (Jenner), Queen Mary, University of London, London, UK; Clinical Trials Research Unit (Ni Mhurchu), The University of Auckland, Auckland, New Zealand; Center for Science in the Public Interest (Jacobson), Washington, DC; and Libin Cardiovascular Institute of Alberta (Campbell), the University of Calgary, Calgary, Alta.
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  • Re:Desk-bound authors do not understand food industry
    Norm RC Campbell
    Posted on: 02 May 2012
  • Desk-bound authors do not understand food industry
    Morton Satin
    Posted on: 19 April 2012
  • Posted on: (2 May 2012)
    Page navigation anchor for Re:Desk-bound authors do not understand food industry
    Re:Desk-bound authors do not understand food industry
    • Norm RC Campbell, physician

    I thank Morton Satin, Vice President, Science and Research, the Salt Institute for his comments on an article relating to the international variation in the salt/sodium content of fast foods (1). To interpret Morton Satins comments, the reader should be aware the Salt Institute is a trade association for the salt producing industry which earns income from ultimately from the sale of salt (www.saltinstitute.org/ accessed A...

    Show More

    I thank Morton Satin, Vice President, Science and Research, the Salt Institute for his comments on an article relating to the international variation in the salt/sodium content of fast foods (1). To interpret Morton Satins comments, the reader should be aware the Salt Institute is a trade association for the salt producing industry which earns income from ultimately from the sale of salt (www.saltinstitute.org/ accessed April 23 2012). The Salt Institute's actions and function appear, to me, to be similar to that of the Tobacco Institute that for decades countered evidence on the harmful effects of tobacco products (http://en.wikipedia.org/wiki/Tobacco_Institute accessed April 23 2012). On its website, the Salt Institute claims to be an authoritative voice on salt and it lobbies national governments. Using a small group of consultants and academics, the Institute issues public and scientific press releases to argue against the science that indicate that dietary salt additives cause much death and disability worldwide. The Salt Institute website even advertizes a video on the 'surprising health benefits of salt' and calls Morton Satin, 'the salt Guru armed only with scientific knowledge about sodium chloride'. The one page outline on dietary salt and health from the Salt Institute claims in enlarged type 'A growing body of research shows salt is GOOD for you ....' (with sub text that implies dietary salt increases longevity and intelligence) 'but LOW -salt diets may HARM you'. Needless to say, the salt industry has a strong and direct financial interest in maintaining or increasing sales of salt. However, that salt companies in Canada (The Canadian Salt Company Ltd., Sifto Canada Corp. (Compass Minerals), NSC Minerals Inc.) and elsewhere have a trade association (based on companies in the United States) that functions to counter the scientific and health care community efforts to improve health represents a societal ethical and moral issue to me.

    Estimates indicate more than one million deaths per year from excess dietary salt in low and middle income countries (2). It is estimated that 120,000 Canadians are being diagnosed with hypertension annually and 2 million Canadians have hypertension related to dietary sodium* (3-6). Reducing dietary salt is cost saving in developed countries, is indicated to be a best buy** for countries to improve the health of their population by the World Health Organization (WHO) and was a key recommendation to prevent chronic disease by the United Nations in 2011 (www.who.int/nmh/publications/ncd_report_chapter4.pdf, accessed April 23 2012). The evidence base used for the dietary salt recommendations is extensive, inclusive and frequently updated. For example, the WHO has just closed public consultation on an updated scientific review with recommendations for dietary salt with the release expected later this year. Most major Canadian national scientific and health care professional organizations have policies in place to support reduction in dietary salt and most have taken substantive actions to support reductions in dietary sodium.

    The World Action on Salt and Health (WASH) is a nongovernment organization with a volunteer membership of scientists and health care professionals who are aiding individuals, organizations and countries to improve population health through reductions in dietary salt (http://www.worldactiononsalt.com/). WASH does not have commercial interests and largely functions to disseminate scientific and health information on dietary salt world-wide. I am a WASH member, which to date has largely entailed receiving informative emails on dietary salt activities from around the world. I have never received any financial support from WASH. I would encourage readers interested in dietary salt and the effort to improve health through reductions in dietary salt to also opt for free membership.

    I should also have noted, I have volunteered as a member (or chair) of committees for other governmental and nongovernmental organizations related to reducing dietary salt including the World Health Organization, Pan American Health Organization, the Public Health Agency of Canada, Health Canada, Hypertension Canada, Canadian Society of Internal Medicine, and the Heart and Stroke Foundation. At the time the manuscript was being written, I was a volunteer member or chair of over 40 committees relating to efforts to improve health through improved management of hypertension or prevention of hypertension or prevention of cardiovascular disease and hence these committees all would have involved efforts to reduce dietary salt directly or indirectly. I have also been a short term consultant or speaker for many regional and national governmental and nongovernmental organizations and meetings relating to dietary salt. Many of these organizations and meetings have provided travel support for me. My salary support is from the Heart and Stroke Foundation of Canada and the Canadian Institute of Health Research and is to provide leadership in efforts to prevent and control hypertension and is currently focused on addressing dietary causes of hypertension. My rationale for focusing on being involved in efforts to reduce dietary salt relates specifically to the extensive evidence of the harmful effects of high dietary salt. In the two countries (Chile and USA ) that have assessed the rank order of health risks that included salt, high salt intake was estimated to be the 2nd and 7th leading risk for death respectively (8)(9). In the past, I have viewed my activities outlined above more as my academic credentials which are documented in much greater detail in my annual university reports than conflicts of interest that required public disclosure. I sincerely apologize to CMAJ readers for overlooking to document potential conflicts of interest. Norm Campbell MD.

    1) Dunford E, Webster J, Woodward M, Czernichow S, Lun Yuan W, Jenner K, Ni Mhurchu C, Jacobson M, Campbell N, Neal B. The variability of reported salt levels in fast foods across six countries -opportunities for salt reduction. CMAJ 2012. DOI:10.1503 2) Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370(9604):2044- 2053. 3) Campbell NRC, Willis KJ, L'Abbe M, Strang R, Young E. Canadian Initiatives to Prevent Hypertension by Reducing Dietary Sodium. Nutrients 2011;3:756-64 4) Legetic B , Campbell N. Pan American Health Organization Actions to Facilitate Cardiovascular Disease Prevention Through Population Based Salt Reduction in the Americas. Journal of Health Communication. 2011;16:37-48 5) Penz ED, Joffres MR, Campbell NRC. Reducing dietary sodium and decreases in cardiovascular disease in Canada. Can J Cardiol. 2008;24:497 -501. 6) Joffres MR, Campbell NRC, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health costs in Canada. Canadian Journal of Cardiology. 2007;23:437-443 7) Robitaille C, Dai S, Waters C, Loukine L, Bancej C, Quach S, Ellison J, Campbell N, Tu K, Reimer K, Walker R, Smith M, Blais C, Quan H. Incidence, prevalence and mortality of diagnosed hypertension in Canada. CMAJ. January 10, 2012 184:E49-E56. 8) Departamento de Epidemiologia Ministerio de Salud. Chilean Health Report. Chilean Health Report , 1-453. 2003. Gobierno De Chile, Ministerio De Salud. 9-20-2010. 9) Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6:e1000058.

    * There were 418,000 Canadians with new diagnoses of hypertension 2007/8 and in 2012 there is an estimated 7.5 million Canadians with hypertension (7); 30% of hypertension in Canada is estimated to be related to excess dietary sodium (6). **A best buy is an intervention that is not only highly cost-effective but also cheap, feasible and culturally acceptable to implement

    Conflict of Interest:

    the letter details my potential interests

    Show Less
    Competing Interests: None declared.
  • Posted on: (19 April 2012)
    Page navigation anchor for Desk-bound authors do not understand food industry
    Desk-bound authors do not understand food industry
    • Morton Satin, Vice President, Science and Research

    I am somewhat surprised that the CMAJ, a journal normally dedicated to higher level clinical studies, would publish what appears to be little more than a high school level internet search of fast food chain websites, complete with conclusions demonstrating a complete lack of understanding of how food is formulated.

    Six out of the 10 authors are members of WASH (World Action on Salt and Health), whose singular...

    Show More

    I am somewhat surprised that the CMAJ, a journal normally dedicated to higher level clinical studies, would publish what appears to be little more than a high school level internet search of fast food chain websites, complete with conclusions demonstrating a complete lack of understanding of how food is formulated.

    Six out of the 10 authors are members of WASH (World Action on Salt and Health), whose singular goal is the international reduction of salt consumption. Their decade-long campaign against salt has been characterized by the complete denial of any peer-reviewed clinical evidence that counters this agenda and cautions against salt reduction. This has become more conspicuous during the last two years, when the overwhelming clinical evidence has clearly highlighted the risks of reducing current salt levels.

    While authors Dunford, Webster, Neal and Jenner note their conflict of interest as members of WASH at the end of the paper, Campbell and Jacobson make no such declaration, even though they are listed as WASH members . While there is no problem with anyone belonging to any sort of advocacy organization, it is important to let readers know if you have an intellectual attachment to a particular side of an issue in order for them to have a better understanding of the objectivity of the author and the motivation of the publication. The very act of refusing to acknowlege such a conflict of interest is in itself telling.

    It is clear that the authors know little about the food industry, nevertheless feel free to make judgments upon it. They do not appear to understand that localized food tastes dictate how foods are formulated. As an example in Canada, the same brand of beer will differ significantly in taste (sweetness, bitterness) depending upon the region it is brewed in, so that local tastes are satisfied. The huge success of micro-breweries are almost entirely due to the products satisfying a localized taste. If a pizza chain based in the US finds that clients in the UK don't like as many anchovies as Americans do, of course the salt content will vary in the pizza between the two countries. You find local differences in the sweetness, spicing, and texture components in versions of same-name international chain products all around the world.

    The authors should also understand that food companies make food, not animal feed. Consumers have choices among products and it is the food industry's business to know the specific food preferences of their clients.

    Food cannot be the same in every country. In Britain, Australia and South Africa, they eat salty autolyzed yeast spread in much the same way as Americans and Canadians eat peanut butter. Chacun a son gout (each to his/her taste) is not an idle expression - it's a reflection of reality.

    Let's not forget that the big secret of the heart healthy Mediterranean diet is that it is higher in salt than the American or Canadian diet. This is understandable because it is a far more traditional diet and traditional foods are far higher in salt than any modern processed foods, because in the past salt was not only used for taste, but also for preservation (a function that has largely been taken over by refrigeration and freezing in more modern diets). Parmesan, gorgonzola, feta, olives, anchovies, prosciutto, salt cod, bottarga, babaganoush, etc., etc., are all very high in salt, yet the people around the Mediterranean have some of the best cardiovascular figures in the world.

    The authors presume that salt reduction is a simple process with no technical difficulties. Yet, when a highly competent company with a household brand name stepped up to the bat and laid its century-long reputation on the line to cater to the wishes of the anti-salt zealots, it proved to be a great and very costly gamble. Making sweeping statements about what the industry should do holds no risks whatsoever for the desk- bound authors of this paper, but it does hold great risks for the food industry.

    And it also holds great risks for the public. If per capita sodium consumption (taken from the Intersalt study) is plotted against life expectancy, the data indicates that the higher the sodium consumption, the higher the life expectancy. While I'm not implying any cause and effect relationship between sodium intake and lifespan, the data does demonstrate the compatibility between life expectancy and the associated levels of sodium intake.

    As I eluded to earlier, the preponderance of peer-reviewed medical studies recently published, have cautioned against population-wide salt reduction (1,2,3,4,5,6,7), including the latest one demonstrating that anyone who follows the 2010 Dietary Guidelines for sodium will end up with a highly unbalanced and nutritionally inadequate diet (8). This evidence proves beyond all doubt that the 2010 Dietary Guideline for sodium is bogus and will do the public far more harm than good. Unfortunately, our public health authorities have neither the courage nor conviction to put things right. It's a pity that they have forgotten that they work for consumers.

    1)Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. Reduced Dietary Salt for the Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials [Cochrane Review]. Am J Hyperten. 2011;24(8):843-853.

    2)Garg R., Williams GH, Hurwitz S, Brown NJ, Hopkins PN, Adler GK. Low-Salt Diet Increases Insulin Resistance in Healthy Subjects, Metabolism. 2010;60(7):965-68. Epub 2010 Oct 30.

    3)Stolarz-Skrzypek K, Kuznwtsova T, Thijs L, et al. Fatal and nonfatal outcomes, incidence of hypertension, and BP changes in relation to urinary sodium excretion. JAMA. 2011;305:1777-1785.

    4)Graudal NA, Hubeck-Graudal T, J?rgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens 2011;25:1-15.

    5)E.I. Ekinci, S. Clarke, M.C. Thomas, et al., Dietary Salt Intake and Mortality in Patients With Type 2 Diabetes, 34 Diabetes Care 703-09 (2011).

    6)Thomas MC, Moran J, Forsblom C, Harjutsalo V, Thorn L, Ahola A, Wad?n J, Tolonen N, Saraheimo M, Gordin D, Groop PH; for the FinnDiane Study Group, The Association between Dietary Sodium Intake, ESRD, and All- Cause Mortality in Patients With Type 1 Diabetes. Diabetes Care. 2011 Apr;34(4):861-866. Epub 2011 Feb 9.

    7)O'Donnell MJ, Yusuf S, Mente A, Gao P, Mann JF, Teo K, McQueen M, Sleight P, Sharma AM, Dans A, Probstfield J, Schmieder RE. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011 Nov 23; 306(20):2229-38.

    8)Maillot M, Drewnowski A. A Conflict between Nutritionally Adequate Diets and Meeting the 2010 Dietary Guidelines for Sodium. Am J Prev Med. 2012;42(2):174-179.

    Conflict of Interest:

    The author is employed by the Salt Institute

    Show Less
    Competing Interests: None declared.
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The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction
Elizabeth Dunford, Jacqueline Webster, Mark Woodward, Sebastien Czernichow, Wen Lun Yuan, Katharine Jenner, Cliona Ni Mhurchu, Michael Jacobson, Norm Campbell, Bruce Neal
CMAJ Jun 2012, 184 (9) 1023-1028; DOI: 10.1503/cmaj.111895

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The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction
Elizabeth Dunford, Jacqueline Webster, Mark Woodward, Sebastien Czernichow, Wen Lun Yuan, Katharine Jenner, Cliona Ni Mhurchu, Michael Jacobson, Norm Campbell, Bruce Neal
CMAJ Jun 2012, 184 (9) 1023-1028; DOI: 10.1503/cmaj.111895
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