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Bulletin of the World Health Organization logoLink to Bulletin of the World Health Organization
. 2023 May 15;101(7):453–469. doi: 10.2471/BLT.23.289992

Sodium content targets for pre-packaged foods, China: a quantitative study and proposal

Objectifs relatifs à la teneur en sodium des aliments préemballés en Chine: étude quantitative et proposition

Objetivos sobre el contenido de sodio de los alimentos preenvasados, China: estudio cuantitativo y propuesta

المحتوى المستهدف من الصوديوم في الأغذية سابقة التعبئة، الصين: دراسة كمية واقتراح

中国预包装食品钠含量指标：定量研究与建议

Целевые показатели содержания натрия в предварительно расфасованных продуктах питания, Китай: количественное исследование и предложение

Puhong Zhang a, Jiguo Zhang b, Yuan Li a, Le Dong a, Feng J He c, Mhairi Brown c, Simone Pettigrew d, Jacqui Webster d, Rain Yamamoto e, Chizuru Nishida e, Aidong Liu f, Xiaoguang Yang b, Bing Zhang b, Gangqiang Ding b, Huijun Wang b,✉
PMCID: PMC10300770  PMID: 37397173

Abstract

Objective

To determine the contribution of pre-packaged foods to population sodium intake in China, and to propose sodium content targets for food subcategories used for the World Health Organization’s (WHO’s) global sodium benchmarks.

Methods

The impact of four different approaches to reducing the sodium content of pre-packaged foods on population sodium intake was estimated using data from national databases covering the nutrient content and ingredients of 51 803 food products and food consumption by 15 670 Chinese adults. We recategorized food products using a food categorization framework developed for WHO’s global sodium benchmarks and adapted for China-specific foods.

Findings

Pre-packaged foods, including condiments, contributed 1302.5 mg/day of sodium intake per adult in 2021, accounting for 30.1% of population sodium intake in China. Setting maximum sodium content levels using a 90th-percentile target would reduce sodium intake from pre-packaged foods by 96.2 mg/day, corresponding to a 1.9% reduction in population intake. Using the 75th-percentile, a fixed 20% reduction and WHO benchmark targets would further reduce intake by 262.0 mg/day (5.2% population intake), 302.8 mg/day (6.0% population intake) and 701.2 mg/day per person (13.9% population intake), respectively. Maximum sodium content levels based on revised 20% reduction targets were proposed because they should result in substantial and acceptable reductions in sodium content for most food subcategories: overall sodium intake would decline by 305.0 mg/day per person, and population intake by 6.1%.

Conclusion

This study provides the scientific rationale for government policy on setting targets for food sodium content in China. Simultaneous action on discretionary salt use should also be taken.

Introduction

Sodium is an essential nutrient for which humans have a physiological need of as little as 200 to 500 mg/day.1,2 The primary dietary contributor is the salt (i.e. sodium chloride) added during cooking or at the table, and hidden in processed foods. One gram of sodium is equivalent to 2.5 g of salt. Other sodium compounds, such as sodium glutamate, and some other food additives may also contribute to sodium intake.

Excessive sodium intake is associated with an increase in blood pressure and the risk of cardiovascular diseases and other chronic conditions.3–6 Global burden of disease studies showed that excessive sodium intake led to 1.7 million deaths in China and 3.2 million deaths globally in 2017.7,8 The World Health Organization (WHO) strongly recommends a sodium intake for adults of less than 2 g/day (i.e. 5 g/day of salt).9 However, the current global average salt intake is estimated to be 10.78 g/day per person, which is more than double WHO’s recommendation and far exceeds physiological requirements.10

In many developed countries, pre-packaged food accounts for more than three quarters of population sodium intake.11 Consequently, one of the best strategies for reducing sodium intake has been to harness the food industry to reformulate products by gradually lowering targets for sodium content.12 WHO reports that 65 countries around the world, mostly high- or middle-income countries, have implemented this policy.10

In 2021, WHO established global sodium benchmarks for 58 subcategories of food that were based on the lowest feasible maximum value for each subcategory, as defined in existing national or regional targets.13 These benchmarks provide a clear reference point for countries wishing to set or develop maximum sodium levels for foods. However, strategies for gradually reducing the sodium content of foods must avoid sharp reductions and the associated taste shock for consumers, especially in countries like China where dietary sodium primarily comes from cooking or table salt, and where consumers’ taste preferences are largely influenced by foods prepared at home and in restaurants.11,14–17

Although the recommended sodium intake for individuals in China is the same as WHO’s recommendation, the national goal set in 2016 was to reduce the population sodium intake by 20% by 2030,18 which is more conservative than WHO’s comparable global target of a 30% reduction by 2025.13 As around 80% of sodium intake in China comes from salt and condiments added during cooking,19,20 the government has been implementing several national salt reduction programmes since the 1990s that target catering and family cooks.21 As a result, average household salt use decreased from 10.4 g/day per person in 2010 to 2012 to 9.3 g/day per person in 2015,22 still above recommended level.

Nevertheless, despite the continuing increase in the sale of pre-packaged food in China and the relatively high sodium content of pre-packaged food,23–27 efforts to reduce sodium content by promoting food reformulation in the country have been very limited. Until now, except for policy on the mandatory labelling of the sodium content of pre-packaged foods, no official regulation has been issued to incentivize industry to reduce salt use. There exists only the set of voluntary sodium targets included in the Guideline for Salt Reduction for the Chinese Food Industry, which was issued in 2019.28 The Guideline sets mean and maximum levels for the sodium content of individual food categories in China's unique food categorization framework, but sodium target levels were derived using data on only 9000 food products.

With the aim of accelerating the reduction in population sodium intake in China by reformulating pre-packaged foods, we explored the contribution of these foods to sodium intake, and assessed the potential impact of different approaches to reducing the sodium content of foods on population intake. In addition, we propose a set of maximum sodium target levels for different food subcategories to inform government policy on target setting.

Methods

The study involved data from two national databases covering the nutrient content and ingredients of pre-packaged foods and food consumption by Chinese adults, respectively. This study was approved by the Institutional Review Board of the National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention (no. 2018–005).

The Chinese pre-packaged food database contains information on the nutrient content and ingredients of pre-packaged foods available for sale on the Chinese market.29 Data collection started in March 2017 using Shixianzhi, a local FoodSwitch app (George Institute for Global Health, Newtown, Australia) for WeChat (Tencent Holdings Ltd, Shenzhen, China).25,30 Between 2017 and 2018, data on 32 000 products were collected from the top 10 supermarkets in two provincial capitals in north and south China, respectively. Since January 2019, the food database has constantly been supplemented by consumers nationwide using crowdsourcing.29,31 During crowdsourcing, data were collected only on products that did not already exist in the Shixianzhi database to avoid duplication. For this study, we examined data on 76 354 products collected between March 2017 and February 2021. We excluded products that contained almost no sodium, pure sodium compounds, baby foods and products whose sodium content was unknown.

Food consumption data were obtained from the China Health and Nutrition Survey,32 an ongoing longitudinal household-based survey initiated in 1989 and conducted every 2 to 4 years, that was established to study the effect of socioeconomic change on nutrition and health. Households across different geographical regions of China with varying levels of economic development were selected using a multistage, random-cluster, sampling strategy.32 In each survey, trained interviewers interviewed all family members. Information on the consumption of individual foods was collected using three consecutive 24-hour dietary recalls on two weekdays and one weekend day, respectively. The name and amount of each food consumed, including pre-packaged foods, were recorded.33 For our study, we used data on pre-packaged food consumption collected in 2018 from all 15 670 adult survey participants in 15 provinces.

Initially, food products were categorized using a hierarchical category tree developed by the Global Food Monitoring Group.34 However, for our study, we recategorized all products in line with the food categorization framework used for WHO’s global sodium benchmarks.13 During this process, we excluded the existing category 5 (edible ices) because there was no product in this category on the Chinese market, and we added a new category 19 (egg and egg products) because there were hundreds of egg products with a relatively high sodium content in China. In addition, we added some new subcategories and redefined or expanded the descriptions of some subcategories to take into account China-specific food products. Details are available from the online repository.35 The original WHO category and subcategory names were unchanged. Our analysis and results are based on this adapted categorization.

Statistical analysis

All sodium content values were converted into mg/100 g of food product. For each product subcategory, sodium content is described using the mean, standard deviation (SD), standardized SD (i.e. the SD divided by the mean), minimum, maximum and the 25th, 50th (i.e. median), 75th and 90th percentiles.

The population sodium intake attributable to pre-packaged foods is the sum of the sodium intake of all individual food subcategories and is expressed in mg/day per person. Sodium intake from each subcategory was calculated as the median sodium content of foods in the subcategory (in mg/100 g) multiplied by their consumption (in g/day per person) and divided by 100, where consumption of food in a subcategory (in g/day per person) was the total amount of food in the subcategory consumed over three days by all survey participants (in g) divided by the total number of participants and divided by 3.

Following the approach used to establish WHO’s sodium benchmarks, we decided to set individual maximum sodium target levels for each food subcategory. We considered three different types of targets in exploring suitable maximum sodium food content levels: (i) percentile targets; (ii) fixed percentage reduction targets; and (iii) WHO benchmarks. With the 75th percentile target, the 25% of food products in each subcategory that had a sodium content above the 75th percentile for that subcategory were reformulated to ensure their sodium content did not exceed the existing 75th percentile. With the 90th percentile target, an analogous 10% of food products in each subcategory were reformulated to ensure their sodium content did not exceed the 90th percentile. For a fixed percentage reduction target, the goal was to achieve a fixed percentage reduction in mean sodium content from baseline in each subcategory. With this approach, the projected maximum sodium content of individual food products in a subcategory was reduced reiteratively in steps of 1 mg/100 g until the desired percentage reduction in the mean sodium content of the whole subcategory was achieved. In each step, only products with a sodium content above the maximum for that step would have to be reformulated. In our study, we considered only a 20% reduction in sodium content, which reflects the national goal of a 20% reduction in sodium intake by 2030.

Several indicators were used to reflect the impact of different maximum sodium target levels on the number of foods to be reformulated and on sodium intake, and to guide the selection of the most suitable targets. It was assumed that target levels had been achieved and that the sodium content of products would not change once these targets had been achieved. The indicators were: (i) the proportion of products in each food subcategory that would have to be reformulated (i.e. the proportion of products with a sodium content above the subcategory target); (ii) the resulting reduction in mean sodium content for each subcategory (i.e. the difference in the mean sodium content of foods in the subcategory, before and after reformulation, in mg/100 g); (iii) the resulting reduction in population sodium intake from a subcategory, in mg/day per person, calculated as the reduction in sodium content for the subcategory (in mg/100 g) multiplied by the amount consumed from the subcategory (in g/day per person) and divided by 100; and (iv) the resulting reduction in sodium intake from all pre-packaged foods (i.e. the sum of the individual reductions across all subcategories).

The impact of different target levels could be seriously affected by the distribution of, or variation in, sodium content across foods in a subcategory. Consequently, to help identify the most suitable targets, we drew scatter plots to visualize the relationship between: (i) the reduction in mean sodium content achieved in a subcategory if targets were met, and the standardized SD in sodium content for that subcategory; and (ii) the proportion of products in a subcategory that would have to be reformulated if targets were met, and the standardized SD in sodium content for that subcategory.

Selection of maximum targets

Our recommended sodium target levels were based on two criteria. First, the targets should result in a relative reduction in sodium intake from all pre-packaged foods consistent with the national 20% reduction goal, while bearing in mind that discretionary salt use, which dominates consumption in China, must be similarly reduced in parallel. Second, the targets should result in a substantial and acceptable reduction in sodium content for each food subcategory, especially for the main sodium contributors, and consider: (i) the effect of the sodium content reduction on consumers’ changing taste for salt; and (ii) the challenges posed to food producers by the number of foods that have to be reformulated.

Results

Of 76 354 pre-packaged food products in the Chinese database, 67 027 (87.8%) were recategorized into 62 subcategories of 18 main categories based on our adapted WHO categorization framework, and 51 803 (67.9%) in 55 subcategories of 15 main categories were eligible for inclusion in the analysis (Fig. 1). The 2018 China Health and Nutrition Survey reported on 3020 products in 51 subcategories consumed by 15 670 adults. Details of consumption for each food subcategory are available from the online repository.35

Fig. 1.

Selection of food products for sodium reduction analysis, China, 2021

WHO: World Health Organization.

Note: Food subcategories were derived from the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

Fig. 1

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Sodium content of foods

The sodium content of different Chinese food product subcategories is listed in Table 1 and is described in detail in the online repository.35 Mean sodium content ranged from 93 mg/100 g to 7129 mg/100 g and the standardized SD ranged from 0.38 to 2.82. Sodium intake per adult from pre-packaged foods based on the median sodium content of individual subcategories was 1302.5 mg/day (i.e. 3.3 g of salt; Table 2); this accounted for 30.1% of population salt intake in China, which was 11 g/day per person in 2020.36 The subcategory of soy sauce and fish sauce contributed most to sodium intake (median: 616.6 mg/day per person, which accounted for 47.3% of the 1302.5 mg/day from all pre-packaged foods), followed by the categories of ready-to-eat meals, and of salted butter, butter blends, margarine and oil-based spreads. The top six and top 12 subcategories accounted for 83.4% and 95.1% of sodium intake from all pre-packaged foods, respectively (Table 2).

Table 1. Sodium content of pre-packaged foods, by subcategory, China, 2021.

Food product subcategory classification and descriptiona,b
(n = 55)		 No. food products in subcategory Sodium content of food productsc (mg/ 100 g)d
Mean (SD) Standardized SDe Median (IQR) Minimum–Maximum
  18aii. Bouillon and soup stock (concentrated) 217 7 129 (6 776) 0.95 5 682 (2 956–8 327) 10–53 000
  9gii. Soups (dry soup only; concentrated) 221 5 261 (4 605) 0.88 4 624 (1 450–8 330) 6–25 606
  18f. Soy sauce and fish sauce 1898 5 213 (2 436) 0.47 5 195 (3 600–6 830) 10–17 692
  18h. Marinades and thick pastes 2018 4 115 (5 746) 1.40 2 418 (403–5 118) 10–77 726
  18e. Condiments 785 2 855 (2 145) 0.75 2 553 (1 527–3 780) 3–30 813
  14c. Processed fish and seafood products, non-heat-treated 76 2 581 (1 737) 0.67 1 710 (1 234–4 892) 25–5 490
  18g. Other Asian-style sauces 22 2 262 (1976) 0.87 1 914 (605–3 758) 72–8 200
  16b. Pickled vegetables 1799 1 903 (1 595) 0.84 1 770 (1 064–2 292) 7–26 891
  17b. Meat analogues 44 1 706 (1 136) 0.67 1 534 (786–2 412) 154–6 500
  9bii. Pasta, noodles and rice or grains with sauce or seasoned (dry mix, concentrated) 2448 1 646 (2 171) 1.32 1 347 (482–2 130) 2–32 024
  14h. Comminuted meat products, non-heat preservation 124 1 566 (954) 0.61 1 440 (791–2 211) 37–5 910
  14i. Processed fish and seafood, heat-treated (cooked) 1231 1 413 (1 050) 0.74 1 337 (854–1 694) 9–18 550
  14f. Whole muscle meat products, non-heat preservation 1551 1 411 (537) 0.38 1 460 (1 047–1 708) 18–9 447
  19b. Processed eggs and egg products 280 1 160 (1 361) 1.17 816 (621–1 396) 125–20 800
  18b. Cooking sauces including pasta sauces and tomato sauces (not concentrated) 717 1 151 (1 869) 1.62 546 (325–981) 6–22 200
  14g. Comminuted meat products, heat-treated (cooked) 2759 1 131 (575) 0.51 1 037 (834–1 349) 17–14 519
  14eii. Whole muscle meat products, heat-treated (refrigerated products) 65 962 (602) 0.63 886 (420–1 370) 6–2 960
  18d. Emulsion-based dips, sauces and dressings 196 950 (758) 0.80 760 (600–1 196) 10–9 030
  17a. Tofu and tempeh 911 936 (612) 0.65 929 (636–1 212) 3–6 573
  9f. Ready-to-eat meals composed of a combination of carbohydrate and either vegetable or meat, or all three combined 1287 873 (987) 1.13 463 (120–1 232) 4–5 683
  14ei. Whole muscle meat products, heat-treated (frozen and canned products) 264 818 (486) 0.59 750 (598–932) 30–3 530
  14a. Canned fish 418 791 (551) 0.70 660 (431–976) 62–5 200
  14b. Processed fish and seafood products, raw 425 783 (1 542) 1.97 417 (192–690) 1–17 706
  3d. Extruded snacks 2968 773 (737) 0.95 570 (311–874) 6–5 683
  8a. Fresh unripened cheese 14 721 (570) 0.79 550 (291–952) 117–1 969
  16c. Olives and sundried tomatoes 4083 714 (1 837) 2.57 91 (22–519) 1–27 780
  3c. Potato, vegetable and grain chips 1988 690 (523) 0.76 593 (399–838) 6–9 702
  14d. Raw meat products and preparations 443 639 (899) 1.41 536 (316–735) 5–10 320
  8c. Semi-hard ripened cheese 196 636 (491) 0.77 600 (320–745) 10–3 500
  16g. Battered or breaded vegetables 43 590 (1 266) 2.15 258 (111–570) 10–8 000
  8g. Processed cheese 126 583 (413) 0.71 471 (243–900) 30–1 903
  9gi. Soups (ready-to-serve, canned and refrigerated soups) 14 553 (453) 0.82 356 (263–507) 232–1 660
  3a. Crackers and savoury biscuits 955 490 (285) 0.58 480 (294–634) 3–2 943
  9c. Pizza and pizza snacks 58 471 (222) 0.47 410 (336–544) 72–1 220
  9d. Sandwiches and wraps 79 457 (284) 0.62 388 (260–616) 20–1 398
  3b. Nuts, seeds and kernels 3368 414 (559) 1.35 298 (86–574) 1–7 156
  10a. Salted butter, butter blends, margarine and oil-based spreads 59 405 (328) 0.81 480 (20–695) 6–1 000
  12. Fresh or dried pasta, noodles, rice and grains 2680 398 (653) 1.64 192 (14–650) 1–20 100
  18c. Dips and dipping sauces 331 340 (958) 2.82 23 (10–62) 2–5 048
  11c. Flatbreads 117 321 (223) 0.69 304 (179–411) 6–1 417
  1b. Nut butters 46 313 (169) 0.54 334 (196–488) 9–536
  2e. Pancakes, waffles and French toast 68 292 (135) 0.46 292 (200–363) 70–970
  11b. Leavened bread 370 282 (163) 0.58 255 (193–361) 2–1 640
  2g. Dry mixes for making cakes, sweet biscuits, pastries and other sweet bakery wares 62 268 (169) 0.63 238 (182–305) 29–879
  2a. Cookies and sweet biscuits 5191 261 (174) 0.67 230 (140–347) 6–1 382
  11a. Sweet and raisin breads 817 240 (113) 0.47 222 (180–277) 9–1 404
  4a. Solids and powders 3286 226 (542) 2.40 145 (50–250) 1–9 810
  1a. Granola and cereal-type bars 156 201 (137) 0.68 180 (101–276) 5–930
  2b. Cakes and sponges 1743 201 (179) 0.89 180 (98–271) 2–3 110
  2c. Pies and pastries 1110 194 (268) 1.38 132 (57–235) 2–2 969
  9bi. Pasta, noodles and rice or grains with sauce or seasoned (prepared) 167 193 (404) 2.09 37 (25–85) 1–2 361
  6b. Highly processed breakfast cereals 1122 175 (242) 1.38 100 (30–236) 2–2 300
  9e. Prepared salads 5 154 (65) 0.42 140 (125–174) 79–253
  2d. Baked and cooked desserts 92 120 (162) 1.34 68 (41–110) 6–885
  6a. Minimally processed breakfast cereals (includes all types – prepared, ready-made and dry mixes) 290 93 (146) 1.57 20 (8–146) 2–1 080
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IQR: interquartile range; SD: standard deviation.

a Subcategories are ordered from high to low according to their mean sodium content.

b Food subcategories were based on the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

c The sodium content of food products was derived from the FoodSwitch database.31

d All figures are in mg/100 g except for the standardized SD

e The standardized SD is the SD divided by the mean.

Table 2. Contribution of pre-packaged foods to population sodium intake, by subcategory, China, 2021.

Food product subcategory classification and descriptiona,b,c
(n = 43)		 Parameters for food products in subcategory
Median sodium content,d mg/100 g Consumption,e g/day per person Sodium intake,f mg/day per person % of total sodium intake
  18f. Soy sauce and fish sauce 5195 11.87 616.60 47.34
  9f. Ready-to-eat meals composed of a combination of carbohydrate and either vegetable or meat, or all three combined 463 31.11 144.10 11.06
  10a. Salted butter, butter blends, margarine, and oil-based spreads 480 19.13 91.80 7.05
  9bii. Pasta, noodles and rice or grains with sauce or seasoned (dry mix, concentrated) 1347 6.41 86.30 6.62
  16b. Pickled vegetables 1770 4.81 85.20 6.54
  14f. Whole muscle meat products, non-heat preservation 1460 4.29 62.60 4.81
  17a. Tofu and tempeh 929 4.36 40.50 3.11
  18b. Cooking sauces including pasta sauces and tomato sauces (not concentrated) 546 5.52 30.10 2.31
  18e. Condiments 2553 0.89 22.60 1.74
  14g. Comminuted meat products, heat-treated (cooked) 1037 2.12 21.90 1.68
  14h. Comminuted meat products, non-heat preservation 1440 1.38 19.90 1.53
  18h. Marinades and thick pastes 2418 0.71 17.20 1.32
  11b. Leavened bread 255 4.89 12.50 0.96
  3a. Crackers and savoury biscuits 480 2.09 10.00 0.77
  14i. Processed fish and seafood, heat-treated (cooked) 1337 0.61 8.20 0.63
  12. Fresh or dried pasta, noodles, rice and grains 192 3.41 6.50 0.50
  9gii. Soups (dry soup only; concentrated) 4624 0.13 6.20 0.48
  18g. Other Asian-style sauces 1914 0.26 5.00 0.39
  14b. Processed fish and seafood products, raw 417 0.70 2.90 0.22
  2b. Cakes and sponges 180 1.06 1.90 0.15
  4a. Solids and powders 145 1.30 1.90 0.14
  3b. Nuts, seeds and kernels 298 0.53 1.60 0.12
  3d. Extruded snacks 570 0.24 1.40 0.10
  2c. Pies and pastries 132 0.82 1.10 0.08
  19b. Processed eggs and egg products 816 0.10 0.80 0.06
  14c. Processed fish and seafood products, non-heat-treated 1710 0.04 0.80 0.06
  3c. Potato, vegetable and grain chips 593 0.12 0.70 0.05
  2a. Cookies and sweet biscuits 230 0.19 0.40 0.03
  2d. Baked and cooked desserts 68 0.40 0.30 0.02
  6b. Highly processed breakfast cereals 100 0.27 0.30 0.02
  6a. Minimally processed breakfast cereals (includes all types – prepared, ready-made and dry mixes) 20 1.20 0.20 0.02
  16c. Olives and sundried tomatoes 91 0.23 0.20 0.02
  9d. Sandwiches and wraps 388 0.05 0.20 0.02
  9bi. Pasta, noodles and rice or grains with sauce or seasoned (prepared) 37 0.37 0.10 0.01
  2e. Pancakes, waffles and French toast 292 0.04 0.10 0.01
  14a. Canned fish 660 0.02 0.10 0.01
  8c. Semi-hard ripened cheese 600 0.01 0.10 0.01
  1b. Nut butters 334 0.02 0.10 0.01
  14d. Raw meat products and preparations 536 0.01 0.10 0.00
  18d. Emulsion-based dips, sauces and dressings 760 0.00 0.00 0.00
  18aii. Bouillon and soup stock (concentrated) 5682 0.00 0.00 0.00
  18c. Dips and dipping sauces 23 0.07 0.00 0.00
  1a. Granola and cereal-type bars 180 0.00 0.00 0.00
  Total NA NA 1302.5 100.00
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NA: not applicable.

a In 2021, the China Health and Nutrition Survey recorded no consumption for 12 of the 55 subcategories listed in Table 1.

b Subcategories are ordered from high to low according to their contribution to population sodium intake.

c Food subcategories were derived from the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

d The sodium content of food products was derived from the FoodSwitch database.31

e Food consumption data were obtained from the China Health and Nutrition Survey for 2018.32

f Population sodium intake from foods in a subcategory was calculated as the median sodium content of foods in the subcategory multiplied by their consumption and divided by 100.

Different types of targets

Table 3 shows the maximum sodium content levels, the proportion of food products to be reformulated, and the estimated sodium content reduction in food subcategories when different types of maximum sodium content target were adopted. To achieve the 90th percentile, 75th percentile, 20% reduction and WHO benchmark targets, 10.0%, 25.0%, 25.0% and 46.9%, respectively, of all food products would have to be reformulated. As a result, sodium intake from pre-packaged foods would fall from a baseline mean of 1514.0 mg/day per person by 96.2 mg/day per person (6.4%; 90th percentile target), 262.0 mg/day per person (17.3%; 75th percentile target), 302.8 mg/day per person (20.0%; 20% reduction) and 701.2 mg/day per person (46.3%; WHO benchmark). The change in mean provides a good estimate of the effect of the targets, because reformulation impacts only products with a particularly high sodium content and, consequently, the median may be little changed. The corresponding reductions in mean population sodium intake with the four targets would be 1.9% (90th percentile), 5.2% (75th percentile), 6.0% (20% reduction) and 13.9% (WHO benchmark), given that 30.1% of population sodium intake comes from pre-packaged foods.

Table 3. Maximum sodium content of food products, reduction in mean sodium content and proportion of products to be reformulated, by sodium reduction target and food product subcategory, China, 2021.

Food product subcategory classification and descriptiona
(n = 55)		 Parameters for food products in subcategory with target achieved
90th percentile targetb
 75th percentile targetc
 20% reduction target
 WHO benchmarks
Maximum sodium content, mg/100 g Estimated decrease in mean sodium content, mg/100 g (%) Maximum sodium content, mg/100 g Estimated decrease in mean sodium content, mg/100 g (%) Maximum sodium content, mg/100 g Proportion of food products to be reformulated,% Estimated decrease in mean sodium content, mg/100 g (%) Maximum sodium content, mg/100 g Proportion of food products to be reformulated, % Estimated decrease in mean sodium content, mg/100 g (%)
1a. Granola and cereal-type bars 354 14.0 (7.0) 276 26.1 (13.0) 227 31.4 40.3 (20.0) NAd 0.0 0.0 (0.0)
1b. Nut butters 520 0.3 (0.1) 488 7.0 (2.2) 325 52.2 62.4 (20.0) NAd 0.0 0.0 (0.0)
2a. Cookies and sweet biscuits 480 15.4 (5.9) 347 36.8 (14.1) 295 33.9 52.1 (20.0) 265 40.3 63.3 (24.3)
2b. Cakes and sponges 360 16.6 (8.3) 271 31.2 (15.5) 239 31.8 40.1 (20.0) 205 40.1 52.5 (26.1)
2c. Pies and pastries 386 33.7 (17.4) 235 58.6 (30.2) 344 13.2 38.7 (20.0) 120 53.6 102.9 (53.1)
2d. Baked and cooked desserts 260 27.4 (22.8) 110 50.8 (42.2) 298 7.6 24.0 (20.0) 100 30.4 53.8 (44.7)
2e. Pancakes, waffles and French toast 412 13.2 (4.5) 363 22.7 (7.8) 272 54.4 58.3 (20.0) 330 35.3 32.1 (11.0)
2g. Dry mixes for making cakes, sweet biscuits, pastries and other sweet bakery wares 437 23.4 (8.7) 305 44.1 (16.4) 280 41.9 53.5 (20.0) NAd 0.0 0.0 (0.0)
3a. Crackers and savoury biscuits 806 23.5 (4.8) 634 51.8 (10.6) 500 40.8 98.1 (20.0) 600 30.5 61.2 (12.5)
3b. Nuts, seeds and kernels 865 63.7 (15.4) 574 111.8 (27.0) 719 16.1 82.7 (20.0) 280 51.8 221.3 (53.5)
3c. Potato, vegetable and grain chips 1 336 53.4 (7.7) 838 128.0 (18.6) 799 27.5 138.1 (20.0) 500 62.9 265.9 (38.5)
3d. Extruded snacks 1 835 84.2 (10.9) 874 222.1 (28.7) 1239 14.0 154.5 (20.0) 520 54.4 359.3 (46.5)
4a. Solids and powders 400 60.1 (26.6) 250 85.9 (38.1) 706 2.6 45.2 (20.0) NAd 0.0 0.0 (0.0)
6a. Minimally processed breakfast cereals (includes all types – prepared, ready-made and dry mixes) 260 16.0 (17.3) 146 33.9 (36.5) 238 11.7 18.5 (20.0) 100 29.3 46.7 (50.4)
6b. Highly processed breakfast cereals 379 34.3 (19.6) 236 57.8 (32.9) 371 10.1 35.1 (20.0) 280 19.7 47.7 (27.2)
8a. Fresh unripened cheese 1 563 45.9 (6.4) 953 139.5 (19.3) 936 28.6 144.2 (20.0) 190 92.9 536.3 (74.4)
8c. Semi-hard ripened cheese 1 260 52.6 (8.3) 745 121.7 (19.1) 723 26.0 127.4 (20.0) 625 45.9 164.5 (25.9)
8g. Processed cheese 1 090 36.3 (6.2) 900 65.3 (11.2) 729 34.9 116.8 (20.0) 720 34.9 119.9 (20.6)
9bi. Pasta, noodles and rice or grains with sauce or seasoned (prepared) 446 79.8 (41.4) 85 146.7 (76.1) 929 8.4 38.6 (20.0) 230 19.8 114.4 (59.3)
9bii. Pasta, noodles and rice or grains with sauce or seasoned (dry mix, concentrated) 2 680 305.4 (18.6) 2130 396.7 (24.1) 2481 13.8 329.1 (20.0) 770 67.4 1032.3 (62.7)
9c. Pizza and pizza snacks 684 32.2 (6.8) 544 53.4 (11.3) 435 46.6 94.3 (20.0) 450 44.8 87.3 (18.5)
9d. Sandwiches and wraps 925 10.4 (2.3) 616 60.6 (13.3) 519 38.0 91.3 (20.0) 430 43.0 127.2 (27.8)
9e. Prepared salads 221 6.3 (4.1) 174 15.8 (10.2) 138 60.0 30.6 (20.0) 390 0.0 0.0 (0.0)
9f. Ready-to-eat meals composed of a combination of carbohydrate and either vegetable or meat, or all three combined 2 657 27.8 (3.2) 1232 306.1 (35.1) 1796 21.2 174.7 (20.0) 250 69.1 679.1 (77.8)
9gi. Soups (ready-to-serve, canned and refrigerated soups) 1 234 35.1 (6.4) 507 180.6 (32.7) 831 21.4 110.5 (20.0) 235 92.9 318.2 (57.5)
9gii. Soups (dry soup only; concentrated) 11 500 281.2 (5.3) 8330 775.5 (14.7) 7330 30.3 1052.2 (20.0) 1200 76.5 4238.5 (80.6)
10a. Salted butter, butter blends, margarine and oil-based spreads 800 4.8 (1.2) 695 26.8 (6.6) 533 47.5 81.1 (20.0) 400 59.3 152.7 (37.7)
11a. Sweet and raisin breads 360 10.7 (4.5) 277 24.0 (10.0) 215 54.7 48.0 (20.0) 310 17.4 17.1 (7.1)
11b. Leavened bread 433 17.2 (6.1) 361 28.8 (10.2) 280 42.7 56.6 (20.0) 330 31.9 37.9 (13.4)
11c. Flatbreads 496 29.1 (9.1) 411 43.4 (13.5) 347 41.0 64.4 (20.0) 320 47.9 76.2 (23.7)
12. Fresh or dried pasta, noodles, rice and grains 1 030 51.4 (12.9) 650 106.4 (26.7) 796 16.1 79.5 (20.0) NAd 0.0 0.0 (0.0)
14a. Canned fish 1 400 62.3 (7.9) 977 132.3 (16.7) 886 32.3 158.0 (20.0) 360 85.6 447.9 (56.6)
14b. Processed fish and seafood products, raw 1 380 267.4 (34.1) 690 370.4 (47.3) 3339 3.8 156.6 (20.0) 270 68.2 556.1 (71.0)
14c. Processed fish and seafood products, non-heat-treated 5 063 18.4 (0.7) 4892 58.0 (2.2) 3302 32.9 516.1 (20.0) 800 90.8 1813.2 (70.3)
14d. Raw meat products and preparations 1 007 110.1 (17.2) 735 154.7 (24.2) 869 15.6 127.9 (20.0) 230 79.0 436.6 (68.3)
14ei. Whole muscle meat products, heat-treated (frozen and canned products) 1 400 46.9 (5.7) 932 124.0 (15.2) 809 40.5 163.7 (20.0) 270 89.4 561.8 (68.7)
14eii. Whole muscle meat products, heat-treated (refrigerated products) 1 580 50.9 (5.3) 1370 90.1 (9.4) 1090 40.0 192.5 (20.0) 600 66.2 452.4 (47.0)
14f. Whole muscle meat products, non-heat preservation 1 934 39.3 (2.8) 1708 79.4 (5.6) 1259 63.0 282.2 (20.0) 950 81.5 505 (35.8)
14g. Comminuted meat products, heat-treated (cooked) 1 740 47.6 (4.2) 1349 112.7 (10.0) 1034 50.3 226.3 (20.0) 540 93.0 603.6 (53.4)
14h. Comminuted meat products, non-heat preservation 2 654 70.3 (4.5) 2211 155.4 (9.9) 1734 46.8 313.0 (20.0) 830 73.4 816.1 (52.1)
14i. Processed fish and seafood, heat-treated (cooked) 2 160 114.5 (8.1) 1694 190.8 (13.5) 1425 44.1 282.6 (20.0) NAd 0.0 0.0 (0.0)
16b. Pickled vegetables 3 069 205.9 (10.8) 2292 329.2 (17.3) 2110 32.2 380.7 (20.0) 550 88.2 1387.3 (72.9)
16c. Olives and sundried tomatoes 1 675 310.5 (43.5) 519 506.4 (71.0) 4745 3.8 142.8 (20.0) 780 20.2 447.9 (62.8)
16g. Battered or breaded vegetables 898 243.0 (41.2) 570 288.0 (48.8) 2928 2.3 118.0 (20.0) 510 27.9 304.1 (51.6)
17a. Tofu and tempeh 1 568 52.0 (5.6) 1212 113.3 (12.1) 992 43.7 187.0 (20.0) 280 84.5 689.0 (73.6)
17b. Meat analogues 2 696 130.2 (7.6) 2413 174.4 (10.2) 1906 40.9 341.2 (20.0) 250 97.7 1458.6 (85.5)
18aii. Bouillon and soup stock (concentrated) 14 576 875.5 (12.3) 8327 1819.0 (25.5) 10 324 16.1 1425.6 (20.0) 15 000 10.1 832.5 (11.7)
18b. Cooking sauces including pasta sauces and tomato sauces (not concentrated) 3 364 238.9 (20.8) 981 590.3 (51.3) 3456 9.1 230.2 (20.0) 330 74.9 874.0 (75.9)
18c. Dips and dipping sauces 700 224.2 (65.9) 62 308.0 (90.6) 2672 5.4 68.0 (20.0) 360 12.1 262.0 (77.1)
18d. Emulsion-based dips, sauces and dressings 1 573 77.9 (8.2) 1196 133.2 (14) 1014 35.7 189.9 (20.0) 500 89.3 480.8 (50.6)
18e. Condiments 4 972 211.0 (7.4) 3780 404.9 (14.2) 3204 34.9 571.0 (20.0) 650 91.7 2229.0 (78.1)
18f. Soy sauce and fish sauce 7 900 170.7 (3.3) 6830 357.6 (6.9) 5059 52.5 1042.6 (20.0) 4840 55.2 1160.9 (22.3)
18g. Other Asian-style sauces 4 207 189.4 (8.4) 3758 287.3 (12.7) 3199 31.8 452.4 (20.0) 680 72.7 1692.3 (74.8)
18h. Marinades and thick pastes 9 550 822.1 (20.0) 5118 1532.3 (37.2) 9541 10.2 823.0 (20.0) 1425 63.6 3083.3 (74.9)
19b. Processed eggs and egg products 2 100 115.7 (10.0) 1396 250.5 (21.6) 1473 23.2 232.0 (20.0) NAd 0.0 0.0 (0.0)
Overall NA 96.2 (6.4) NA 262.0 (17.3) NA 25.0 302.8 (20.0) NA 46.9 701.2 (46.3)
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NA: not applicable; WHO: World Health Organization.

a Food subcategories were based on the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

b With the 90th percentile target, 10% of products in each category had to be reformulated.

c With the 75th percentile target, 25% of products in each category had to be reformulated.

d As WHO did not set benchmarks for this subcategory, we assumed no foods had to be reformulated.13

In the analysis, we found that the reduction in mean sodium content with percentile targets varied greatly across subcategories and was positively correlated with the standardized SD for sodium content in the subcategories (Fig. 2). In addition, with the 20% reduction target, the proportion of food products that had to be reformulated in a subcategory correlated negatively with the standardized SD (Fig. 3). In contrast, with the WHO benchmarks, the proportion to be reformulated had no clear association with the standardized SD (Fig. 3). On examining the data in Table 1, Table 2, Table 3, Fig. 2 and Fig. 3 together, we found that several major sodium contributors, such as soy sauce and fish sauce (subcategory 18f) and whole-muscle meat products with non-heat preservation (subcategory 14f), had relatively high and stable sodium contents (i.e. a standardized SD less than 0.5). Although a greater number of products in these two subcategories should be reformulated, the 75th percentile target, for example, would lead to only a small reduction in sodium content (e.g. 6.9% for subcategory 18f and 5.6% for subcategory 14f; Table 3). In contrast, with the 20% reduction target, a fixed reduction in sodium content of 20% would be guaranteed for all subcategories; however, in subcategories with a large, standardized SD, too few products would have to be reformulated.

Fig. 2.

Relationship between the variation in sodium content of food products in a subcategory and the reduction in sodium content with different sodium content targets, China, 2021

SD: standard deviation.

Note: R2 represents the proportion of the variance in the dependent variable (i.e. the reduction in mean sodium content of foods in the subcategory after the target has been achieved) that is explained by the independent variable (i.e. the standardized standard deviation of the sodium content of food products in the subcategory) in a linear regression model. Food subcategories were derived from the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

Fig. 2

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Fig. 3.

Relationship between the variation in sodium content of food products in a subcategory and the proportion of products to be reformulated with different sodium content targets, China, 2021

SD: standard deviation; WHO: World Health Organization.

Note: R2 represents the proportion of the variance in the dependent variable (i.e. the proportion of products to be reformulated in the subcategory) that is explained by the independent variable (i.e. the standardized standard deviation of the sodium content of food products in the subcategory) in a linear regression model. Food subcategories were derived from the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

Fig. 3

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Sodium content targets

Among the different types of sodium content target we investigated, both the 75th percentile and the 20% reduction targets would reduce mean sodium intake from packaged foods by about 20%: the reductions would be 17.3% and 20%, respectively. After taking into account our criteria for selecting suitable targets and the results of our analysis, our initial proposal was that the 20% reduction target should be used for 47 food subcategories, and the 90th percentile target should be used for eight (Table 4). The 90th percentile target was used for the eight subcategories in which fewer than 10% of products would have had to be reformulated if the 20% reduction target were adopted. This proposal could lead to a reduction in sodium intake from pre-packaged foods of 305.0 mg/day per person, which represents a reduction of 20.1% from a baseline mean of 1514 mg/day per person, and a 6.1% reduction in population sodium intake in China. (Table 4).

Table 4. Proposed maximum sodium content targets for food product subcategories and their effect on population sodium intake, China, 2021.

Food product subcategory classification and descriptiona,b
(n = 55)		 Parameters for food products in subcategory
Maximum sodium content target,c mg/100 g Mean sodium content before reformulation, mg/100 g % of products to be reformulated Reduction in mean sodium content after reformulation, mg/100 g (%) Reduction in mean population sodium intake after reformulation,d mg/day per person Proportional contribution to sodium reduction among all pre-packaged foods, % Cumulative contribution to sodium reduction among all pre-packaged foods, %
18f. Soy sauce and fish sauce 5 059 5213 52.5 1043 (20.0) 123.8 40.6 40.6
9f. Ready-to-eat meals composed of a combination of carbohydrate and either vegetable or meat, or all three combined 1 796 873 21.2 175 (20.0) 54.3 17.8 58.4
9bii. Pasta, noodles and rice or grains with sauce or seasoned (dry mix, concentrated) 2 481 1646 13.8 329 (20.0) 21.1 6.9 65.3
16b. Pickled vegetables 2 110 1903 32.2 381 (20.0) 18.3 6.0 71.3
10a. Salted butter, butter blends, margarine and oil-based spreads 533 405 47.5 81 (20.0) 15.5 5.1 76.4
18b. Cooking sauces including pasta sauces and tomato sauces (not concentrated) 3 364e 1151 10.0 239 (20.8) 13.2 4.3 80.7
14f. Whole muscle meat products, non-heat preservation 1 259 1411 63.0 282 (20.0) 12.1 4.0 84.7
17a. Tofu and tempeh 992 936 43.7 187 (20.0) 8.2 2.7 87.4
18h. Marinades and thick pastes 9 541 4115 10.2 823 (20.0) 5.8 1.9 89.3
18e. Condiments 3 204 2855 34.9 571 (20.0) 5.1 1.7 91.0
14g. Comminuted meat products, heat-treated (cooked) 1 034 1131 50.3 226 (20.0) 4.8 1.6 92.5
14h. Comminuted meat products, non-heat preservation 1 734 1566 46.8 313 (20.0) 4.3 1.4 94.0
11b. Leavened bread 280 282 42.7 57 (20.1) 2.8 0.9 94.9
12. Fresh or dried pasta, noodles, rice and grains 796 398 16.1 80 (20.0) 2.7 0.9 95.8
3a. Crackers and savoury biscuits 500 490 40.8 98 (20.0) 2.1 0.7 96.4
14b. Processed fish and seafood products, raw 1 380e 783 9.2 267 (34.2) 1.9 0.6 97.0
14i. Processed fish and seafood, heat-treated (cooked) 1 425 1413 44.1 283 (20.0) 1.7 0.6 97.6
9gii. Soups (dry soup only; concentrated) 7 330 5261 30.3 1052 (20.0) 1.4 0.4 98.1
18g. Other Asian-style sauces 3 199 2262 31.8 452 (20.0) 1.2 0.4 98.4
4a. Solids and powders 400e 226 9.7 60 (26.6) 0.8 0.3 98.7
16c. Olives and sundried tomatoes 1 675e 714 10.0 310 (43.5) 0.7 0.2 98.9
3b. Nuts, seeds and kernels 719 414 16.1 83 (20.0) 0.4 0.1 99.1
2b. Cakes and sponges 239 201 31.8 40 (20.0) 0.4 0.1 99.2
3d. Extruded snacks 1 239 773 14.0 154 (20.0) 0.4 0.1 99.3
2c. Pies and pastries 344 194 13.2 39 (20.0) 0.3 0.1 99.4
9bi. Pasta, noodles and rice or grains with sauce or seasoned (prepared) 446e 193 10.2 80 (41.4) 0.3 0.1 99.5
19b. Processed eggs and egg products 1 473 1160 23.2 232 (20.0) 0.2 0.1 99.6
6a. Minimally processed breakfast cereals (includes all types – prepared, ready-made and dry mixes) 238 93 11.7 18 (19.9) 0.2 0.1 99.7
14c. Processed fish and seafood products, non-heat-treated 3 302 2581 32.9 516 (20.0) 0.2 0.1 99.7
3c. Potato, vegetable and grain chips 799 690 27.5 138 (20.0) 0.2 0.1 99.8
18c. Dips and dipping sauces 700e 340 9.7 224 (65.9) 0.2 0.1 99.9
2d. Baked and cooked desserts 260e 120 10.9 27 (22.8) 0.1 0.0 99.9
2a. Cookies and sweet biscuits 295 261 33.9 52 (20.0) 0.1 0.0 99.9
6b. Highly processed breakfast cereals 371 175 10.1 35 (20.0) 0.1 0.0 100.0
9d. Sandwiches and wraps 519 457 38.0 91 (20.0) 0.0 0.0 100.0
14a. Canned fish 886 791 32.3 158 (20.0) 0.0 0.0 100.0
2e. Pancakes, waffles and French toast 272 292 54.4 58 (19.9) 0.0 0.0 100.0
14d. Raw meat products and preparations 869 639 15.6 128 (20.0) 0.0 0.0 100.0
8c. Semi-hard ripened cheese 723 636 26.0 127 (20.0) 0.0 0.0 100.0
1b. Nut butters 325 313 52.2 62 (19.9) 0.0 0.0 100.0
1a. Granola and cereal-type bars 227 201 31.4 40 (20.0) 0.0 0.0 100.0
2g. Dry mixes for making cakes, sweet biscuits, pastries and other sweet bakery wares 280 268 41.9 54 (19.9) 0.0 0.0 100.0
8a. Fresh unripened cheese 936 721 28.6 144 (20.0) 0.0 0.0 100.0
8g. Processed cheese 729 583 34.9 117 (20.0) 0.0 0.0 100.0
9c. Pizza and pizza snacks 435 471 46.6 94 (20.0) 0.0 0.0 100.0
9e. Prepared salads 138 154 60.0 31 (19.8) 0.0 0.0 100.0
9gi. Soups (ready-to-serve, canned and refrigerated soups) 831 553 21.4 110 (20.0) 0.0 0.0 100.0
11a. Sweet and raisin breads 215 240 54.7 48 (20.0) 0.0 0.0 100.0
11c. Flatbreads 347 321 41.0 64 (20.1) 0.0 0.0 100.0
14ei. Whole muscle meat products, heat-treated (frozen and canned products) 809 818 40.5 164 (20.0) 0.0 0.0 100.0
14eii. Whole muscle meat products, heat-treated (refrigerated products) 1 090 962 40.0 193 (20.0) 0.0 0.0 100.0
16g. Battered or breaded vegetables 898e 590 11.6 243 (41.2) 0.0 0.0 100.0
17b. Meat analogues 1 906 1706 40.9 341 (20.0) 0.0 0.0 100.0
18aii. Bouillon and soup stock (concentrated) 10 324 7129 16.1 1426 (20.0) 0.0 0.0 100.0
18d. Emulsion-based dips, sauces and dressings 1 014 950 35.7 190 (20.0) 0.0 0.0 100.0
Total NA NA 26.0f NA 305.0 100.0 100.0
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NA: not applicable.

a Subcategories are ordered from high to low according to their proportional contribution to the reduction in population sodium intake on achievement of the targets.

b Food subcategories were derived from the World Health Organization’s food categorization framework,13 with some adaptation to take China-specific food products into account.

c Targets were based on the 20% reduction target, except where indicated by the superscript letter e.

d For each subcategory, the reduction in population sodium intake was calculated as the reduction in mean sodium content (mg/100 g) multiplied by consumption (g/day per person; Table 2) and divided by100.

e The maximum sodium content target for this subcategory was based on the 90th-percentile target.

f The overall proportion of products to be reformulated across all subcategories was the sum of the number of products to be reformulated  in each subcategory divided by the total number of products.

Discussion

Our study was triggered by the establishment of WHO’s global sodium benchmarks for different food categories, and the approach employed in developing those benchmarks. We found that pre-packaged foods accounted for a median sodium intake of 1302.5 mg/day per adult in China, which was 30.1% of population sodium intake. If all pre-packaged foods met WHO’s global sodium benchmarks, sodium intake would be 701.2 mg/day per person (46.3%) lower, equivalent to a 13.9% reduction in mean population sodium intake. After considering different types of sodium content targets for use in China, we proposed a set of revised 20% reduction targets because of their ability to induce a substantial and acceptable reduction in sodium content for most food subcategories.

In 2017, China’s National Nutrition Plan prioritized improving nutrition laws, policies and standards.37 As a key strategy for sodium intake reduction, setting sodium content targets for pre-packaged foods has been a hot topic, but has been held back largely by the lack of robust and reasonable sodium targets. Our proposal of revised 20% reduction targets could be a good starting point because these targets will: (i) encourage the reformulation of food products with a relatively high sodium content; (ii) guarantee a substantial reduction in sodium content (i.e. around 20% for each food subcategory), which may not be noticed by consumers and should be acceptable to most food companies;38,39 and (iii) help achieve the national goal of a 20% reduction in population sodium intake by 2030. Recent modelling indicates that, should the proposed targets be met and maintained until 2030, around 6 million cardiovascular disease events could be prevented.40 Moreover, if this approach proves successful, targets could be gradually lowered further towards WHO’s benchmarks and food reformulation could play a leading role in reducing sodium intake nationally. However, even meeting WHO’s benchmarks would reduce population sodium intake by only 13.9%. Consequently, authorities should simultaneously implement strategies targeting discretionary salt use during cooking and eating at home and in restaurants.

We found that a small number of food subcategories with a high sodium content or a large consumption, or both, accounted for almost 90% of sodium intake and could, if the targets were achieved, contribute almost 90% to the reduction in sodium intake from pre-packaged foods. There is, then, an opportunity to start target setting, voluntarily or mandatorily, with these priority foods, thereby ensuring the initial organizational, supervisory and evaluation workload is low. Other countries have considerable experience in setting targets for priority foods, especially as a starting point.41–43

Mandatory reformulation generally appears to achieve larger reductions in population-wide salt consumption than voluntary reformulation.44 If targets are implemented voluntarily, supportive measures are needed, such as strong government leadership, the threat of government regulation if compliance is low, and robust monitoring with the publication of findings.45

To make full use of WHO’s food categorization framework and ensure comparability between countries, we tried to minimize changes to the framework. We noticed, however, that some subcategories (e.g. various processed meat and egg product subcategories) had very similar sodium concentrations. Further consolidation of these categories might simplify the implementation of food sodium content targets.

Initially, we considered only two strategies for setting maximum targets: (i) fixed percentile targets (e.g. 50th, 75th and 90th percentiles); and (ii) existing maximum targets, such as WHO’s benchmarks. However, subsequent analysis showed that percentile targets had limitations: they resulted in only a very small reduction in the mean sodium content of food subcategories that had a small variation in sodium content between products, even though these products could have a very high sodium content and could be the main contributors to dietary sodium. For this reason, we proposed targets based on the 20% reduction strategy. We did not simulate the impact of targets included in the Guideline for Salt Reduction for the Chinese Food Industry because these targets were based on only around 9000 food products compared with our 51 803, and because they were derived by simply multiplying the highest sodium content in individual food categories by 90% or 80%.28 Moreover, we wanted to build on WHO’s sodium benchmarks, and the Guideline’s food categorization framework is totally different from WHO’s framework.

Our study had several limitations that could affect the extrapolation of our findings. First, we excluded some products that naturally contain sodium but no added salt, such as milk. Although this is reasonable when evaluating the effect of food reformulation on sodium intake, we may have slightly underestimated the overall contribution of pre-packaged foods to population sodium intake, and slightly overestimated the relative effect of sodium content reduction. Second, consumption-weighted sodium content reduction was based on the consumption of foods in a subcategory as a whole rather than on the consumption of individual foods. This approach may have influenced our calculations for subcategories in which the consumption of different products was uneven. Third, the consumption data set lacked participating families from west China, where the consumption of pre-packaged foods is likely to be lower than in central and east China. This exclusion may have led to the contribution of pre-packaged foods to sodium intake being overestimated. Fourth, we did not consider setting targets for priority food categories in the study, although our findings help make this possible.

In conclusion, pre-packaged food contributes to nearly one-third of population sodium intake in China and its market share is increasing. Reformulating foods is an important part of the solution. Although they will not bring sodium intake down to the level achievable with WHO’s global sodium benchmarks, our revised 20% reduction targets provide a valuable starting point for government policy. We strongly recommend that action on dietary salt in China should involve comprehensive strategies that simultaneously target both sodium in pre-packaged food and discretionary salt use.

Acknowledgments

Puhong Zhang and Jiguo Zhang contributed equally to this work. We thank Ms Ying Cui, Dr Kathy Trieu and Dr Emalie Rosewarne.

Funding:

This research was funded by the National Institute for Health Research (grant 16/136/77) using aid from the Government of the United Kingdom of Great Britain and Northern Ireland to support global health research. The China Health and Nutrition Survey was supported by the United States of America National Institutes of Health (grants R01-HD30880, DK056350, R24 HD050924 and R01-HD38700) from 1989 to 2019.

Competing interests:

FJH is an unpaid member of Action on Salt and World Action on Salt, Sugar and Health (WASSH). The other authors declare no competing interests.

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