Bread features heavily in many diets worldwide, and is one of the biggest sources of salt in diets. A new survey (4) by World Action on Salt and Health (WASH), based at Queen Mary University of London, has revealed the shocking levels of salt present in this essential staple. WASH surveyed over 2,000 white, wholemeal, mixed grain and flat breads from 32 countries and regions, including over 500 products from Canada collected by Professor Mary L'Abbe's lab at the University of Toronto.

Researchers found that the saltiest bread in the survey -- Rosemary Foccacia by ACE Bakery, available in Canada -- had a shocking 2.65g of salt (1060mg sodium) per 100g, which is saltier than seawater (1). In fact, 73% of Canadian breads exceeded Health Canada's 2016 targets for sodium in bread products and 21% were above recommended maximum levels.

In Canadians more than 1 year of age, bread contributes the most sodium to dietary intakes (14%), primarily because it is consumed in large quantities (7). While voluntary sodium reduction benchmark targets exist in Canada, there is currently no federal or provincial sodium-monitoring program to track the food industry's progress, although aggregate data was published by Health Canada earlier this year (8).

Previous research by Professor L'Abbe's lab has examined industry's progress between 2010 and 2013 and found only a 6.6% reduction in bread products (9). Reducing salt in bread is an easy and effective way of lowering salt intake across the whole population -- research has shown that the salt content of bread could be lowered by 25% over 6 weeks and consumers would not notice the difference (10).

More than 40% (44%) of white breads included in the WASH survey had more salt than the UK's maximum salt target. The Republic of Macedonia produced white breads with the highest salt content, averaging 1.42g/100g, compared to China which had the lowest average salt content of 0.65g/100g. Canadian breads in this category had an average salt content of 1.23g/100g, ranging from 0.43g/100g to 2.65g/100g.

Despite the UK's progress with salt reduction to date5, the average salt content of wholemeal breads from Qatar, China, Costa Rica and South Africa (0.78g/100g -- 0.92g/100g) were lower than the average salt content of wholemeal breads in the UK (0.93g/100g). This suggests that mandatory salt reduction targets, such as those put in place in South Africa (6), may be more effective than voluntary targets.

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Although mixed grain breads had the lowest salt content of the bread categories, there was still a huge variation within this category. The highest salt bread available in Bulgaria had a salt content of 2.50g/100g, compared to the lowest salt bread available in Costa Rica with a salt content of 0.09g/100g, a massive 27-fold difference in salt content. In Canada the highest salt bread in this category had a salt content of 1.69 g/100g and the lowest 0.46 g/100g.

A recent survey by WASH11 found that a third of respondents felt that the WHO could do more to encourage countries to lower salt intakes. However, the majority of respondents felt that their country's government should take primary responsibility.

Professor Mary L'Abbe at the University of Toronto says: "Although recent Health Canada data has documented some progress in the reduction of sodium in prepackaged foods, Canadian bread products surveyed here demonstrate that more work is needed to meet recommended levels"

Mhairi Brown, Nutritionist at WASH, says: "This survey clearly demonstrates the progress still to be made to lower salt intake by 30% by 2025, in line with WHO recommendations. Bread is an essential staple food in many countries but is still a key source of salt in our diets due to the frequency with which we eat bread. Globally we must do more to reduce salt intake, and a simple way to do this is to lower salt in our staple foods."

Graham MacGregor, Professor of Cardiology at Queen Mary, University of London, and WASH Chairman says: "Eating too much salt puts up our blood pressure, the major cause of strokes, heart attacks and heart failure, the leading cause of death and disability worldwide. Reducing salt intake around the world would save millions of lives each year and all countries should be working towards reducing salt intake by 30% by 2025. Our survey has shown that many bread manufacturers internationally are still adding huge and unnecessary amounts of salt to their products. Governments must act now and reinvigorate salt reduction work in the food industry."

References

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1. Atlantic seawater contains 1.0g of sodium per 100g, which equates to 2.5g of salt per 100g

2. Public Health England have issued guideline salt targets for over 80 categories of food, which the food industry are encouraged to follow on a voluntary basis. The maximum target for salt levels in bread and bread rolls, without high salt additions, is 1.13g/100g pdf" title="pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604338/Salt_reduction_targets_for_2017.pdf" title="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604338/Salt_reduction_targets_for_2017.pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604338/Salt_reduction_targets_for_2017.pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604338/Salt_reduction_targets_for_2017.pdf">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/604338/Salt_reduction_targets_for_2017.pdf

3. Health Canada. Bureau of Nutritional Sciences. Food Directorate, Health Products and Food Branch. 2012. Guidance for the Food Industry on Reducing Sodium in Processed Foods.

4. Data on UK fresh, packaged breads were collected from all supermarkets (Aldi, ASDA, Co Op, Iceland, Lidl, Marks & Spencer, Morrisons, Sainsburys, Tesco and Waitrose) in October 2017. Product data was collected in store from product packaging using the FoodSwitch Data Collector App, and where not available, captured online from the retailers' website.

Between August 2017 and January 2018, WASH members collected nutrition data from fresh, packaged white, wholemeal, mixed grain and flat breads and rolls, using information printed on packaging or available online via supermarket or manufacturers websites. In Oman, Saudi Arabia and Serbia, salt content was determined using laboratory analysis.

2,318 bread products from 32 countries and regions were included. The survey was not intended to be a comprehensive survey of all available packaged breads in each country but rather to give an indication of salt levels present in widely available breads worldwide. Data was provided by:

Argentina -- Lorena Allemandi, FIC Argentina

Australia -- Clare Farrand, The George Institute, and The Victorian Health Promotion Foundation

Belgium -- Sigrid Lauryssen and Letizia Ceragioli, Test Achats

Brazil -- Eliana Bistriche Giutini, Food Research Centre

Bulgaria -- Vesselka Duleva, National Centre of Public Health and Analyses Bulgaria

Canada -- Mary L'Abbe, University of Toronto

China -- Yuan Li, The George Institute China

Costa Rica -MSc. Adriana Blanco Metzler and Jaritza Vega Solano, INCIENSA

Denmark -- Natasha Selberg, Danish Heart Foundation

Ecuador -- Enrique Teran, Universidad San Francisco de Quito and Isabel Hernandez, Pontificia Universidad Catolica del Ecuador

Finland -- Satu Mannisto, Sanni Aalto and Liisa Valsta, National Institute for Health and Welfare

Greece -- Joanna Avakian, University of Thessaly

Hong Kong S.A.R., China -- Tai Hing Lam, Shiu Lun Au Yeung, Zhi-Ming Mai and Ho Ching Yeung, The University of Hong Kong

Hungary -- Barbara Nagy, National Institute for Pharmacy and Nutrition

India -- Ashok Kanchan, Consumer Voice India

Italy -- Pietro Modesti, University of Florence

Japan -- Naoko Adachi, University of Tokyo, and Yukiko Okami, Hiromi Yamauchi and Katsuyuki Miura, Shiga University of Medical Science

Kuwait -- Nawal M. Al Hamad and Shahad B. Al-Muneer, Public Authority for Food and Nutrition

Malaysia -- Suzana Shahar, Universiti Kebangsaan Malaysia

Morocco -- Abdelfettah Derouiche, Université HassanII Mohammedia FSBM Casablanca

New Zealand -- Helen Eyles, University of Auckland, and UniServices

Nigeria -- Bashir Garba Ahmad, Muhammad Abdullahi Wase Specialist Hospital, Kano State

Oman -- Dr Salima Almamary, Ministry of Health

Qatar -- Roula Malas, Ministry of Public Health

Republic of Macedonia -- Igor Spiroski, Institute of Public Health

Saudi Arabia -- Hessah Abdullah Al-Hussaini, Ministry of Health

Serbia -- Milka Popovic, University of Novi Sad

South Africa -- Pamela Naidoo, Heart and Stroke Foundation South Africa

Spain -- Cecilia Fernandez, OCU, and Lourdes Samaniego Vaesken, Universidad CEU -- San Pablo

Sweden -- Veronika Ohrvik, Livsmedelsverket

UK -- WASH

USA -- Abby Dilk, CSPI

5. WHO recommended salt intake for adults is 5g/day: pdf" title="pdf">http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf" title="http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf">http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf">http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf">http://apps.who.int/iris/bitstream/10665/77985/1/9789241504836_eng.pdf

6. The UK's salt reduction programme set clear targets for the food industry to achieve and, as a result, the salt content of processed food was gradually reduced. As this was done slowly, the public did not notice the difference in taste and there was no reduction in sales. Salt intake fell by 15% in the UK between 2001-2011, preventing thousands of strokes and heart attacks each year

7. Department of Health South Africa. Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act 54 of 1972): Regulations relating to the reduction in certain foodstuffs and related matters. Pretoria: Government Gazette, 2013

8. Garriguet D. Statistics Canada: Health Reports. 2 Vol. 18. Ottawa: Health Statistics Division; 2007. Sodium consumption at all ages.

9. Health Canada. 2018. Sodium Reduciton in Processed Foods in Canada. An evaluation of progress toward voluntary targets from 2012 to 2106. https://www.canada.ca/en/health-canada/services/food-nutrition/legislation-guidelines/guidance-documents/guidance-food-industry-reducing-sodium-processed-foods-progress-report-2017.html

10. Arcand J, Jefferson K, Schermel A, Shah F, Trang S, Kutlesa D, Lou W, L'Abbe MR. 2016. Examination of food industry progress in reducing the sodium content of packaged foods in Canada: 2010 to 2013. Appl Physiol Nutr Metab. 2016 Jun;41(6):684-90.

11. Girgis, S., Neal, B., Prescott, J., Prendergast, J., Dumbrell, S., Turner, C. et al. (2003). A one-quarter reduction in the salt content of bread can be made without detection. European Journal of Clinical Nutrition, 57, 616 -- 620. doi:10.1038/sj.ejcn.1601583

12. In January 2018, WASH issued a survey via Survey Monkey to WASH members, and placed on social media pages, asking for responses to the following questions:

What salt reduction activities are currently in place in your country?

Who is responsible for salt reduction in your country?

Is enough being done to lower salt reduction in your country?

Who should take more action to lower salt intake in your country?

Which country is setting the best example with salt reduction and could be used as a model for other countries?

WASH received 59 responses to the survey.