Table 1.
Salt reduction implementation strategies in countries of the EMR.
| Country | Engagement with Industries and Reformulation | Consumer Education | Front of Pack Labelling | Work in Specific Settings |
|---|---|---|---|---|
| Bahrain | Name of initiative: Determining the percentage of table salt to be added to bakery products Year: 2018 Leadership: Led by the government (MOH) Approach: Salt reduction in Arabic breads: Mandatory (supported by ministerial decree): A 20% annual reduction of salt level in traditional Arab breads from their current levels for five years until reaching the required percentage of 0.5% salt on a dry flour weight basis [144] Mandatory: Reduction in the amount of added salt in baked products during three years starting in 2018 and reaching a percentage of 0.5% salt [145,146] Cheese is under study [144] |
Name of initiative: Determining the percentage of table salt to be added to bakery products Year: 2018 Leadership: Led by the government (MOH) Approach: Mandatory: Nutrition labels of baked products (traditional and European) should specify the amount of added salt [146] |
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| Egypt | Name of initiative: NA Year: 2017 Leadership: Led by government (MOHAP) Approach: Mandatory: ministerial decree to reduce by 30% the salt content of subsidized Baladi Bread—Planned target [31] Other initiatives: Voluntary: Training of bakeries on 20% reduction of salt in bread (Information provided by NFP) |
Name of initiative: Pilot Implementation of 20% Salt Reduction in Subsidized Baladi Bread in Great Cairo Year: 2018–2019 Leadership: Led by the government Approach: Awareness campaigns (Information provided by NFP) Name of initiative: Brief Health Education sessions Year: NA Leadership: NA Approach: Awareness activities to increase consumers’ awareness towards hazards of high salt consumption and motivate them to reduce salt consumption (Information provided by NFP) |
Name of initiative: 100 Million Health Initiative Year: 2019 Leadership: Led by the government (MOH) Approach: Education Setting: Hospital, school, workplace (Information provided by NFP) |
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| Iran | Name of initiative: Adopted legislation for salt levels in several products Leadership: Led by the government Approach: Mandatory 2015: Establishing maximum salt levels in most commonly consumed canned foods such as tomato paste and salty snacks, and all types of bread (1.8%) [91,147,148] 2016–2017: The standard of salt in bread was further decreased to 1% [149,150,151,152]. 2015: The standard of salt in cheese was decreased from 4% to 3% [152,153] 2015: The standard of salt in dough (fermented drink) was decreased from 1% to 0.8% [152,154] 2018: Salt use has been banned in probiotic yogurts [152,155] Improvement of nutrition in public places through policies for reduced salt in food industries and restaurants; sensitizing food producers regarding the reduction of salt in food products [141] (No further details found) |
Public education through TV regarding low salt consumption [141] (No further details found) |
Name of initiative: Nutritional traffic light labelling Year: 2016 Leadership: Led by the government Approach: Mandatory for all imported and domestic packaged foods, except for products that are not chemically processed or formulated, such as vegetables, spices, vinegar, lemon juice, tea, infusions, coffee, honey, dates, flour, and barberry [152] |
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| Jordan | Name of initiative: Reduction of salt in Arabic bread Year: 2019 Leadership: Led by the government (part of reducing salt, sugar, trans fat consumption) Approach: Mandatory for bread; based on partnership with bakeries Target for breads: Less than 1% of dry weight [156] (planned) Name of initiative: NA Year: NA Leadership: Led by the government Approach: Revised already existing legislation to develop benchmarks for salt content in highly consumed foods, including cheeses [144,148] (No further details found) |
Name of initiative: Low salt, sugar, and trans-fat consumption Year: 2018 Leadership: Led by the government (MOH) Approach: Social marketing (e.g., awareness campaigns), dietary guidelines health promotion campaign (No further details found) Information provided by NFP Develop national recommendations for the reduction of salt intake [141] (No further details found) |
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| KSA | Name of initiative: Healthy Food Strategy, vision 2030 Year: 2018 Leadership: Led by the government (SFDA) Approach: Voluntary: SFDA.FD 59 “salt limits in food product” Mandatory: SFDA.FD 2362 “General requirements for bread production” Mandatory: SFDA.FD 57 “Yogurt, Flavoured Yogurt, and Yogurt Drink” Food categories reformulated: Breads, processed meats, ready meals, breakfast cereals, cheeses, butter and margarines, salty snacks, biscuits and cakes, and soups and sauces Targets for breads (mandatory): 1.0 g/100 g of bread (all types of bread) [157,158,159,160] Mandatory salt limit for yogurt drink (Ayran Laban): 1 g/100 mL [160] |
Name of initiative: Healthy Food Strategy, vision 2030 Year: 2018 Leadership: Led by the government (SFDA) Approach: Social marketing, events, social media posts [159,161] Name of initiative: Warns of Salt Excessive Consumption, Presents Substitutes Year: 2017–2020 Leadership: Led by the government (MOH and SFDA) Approach: Awareness video, guides and campaigns [162,163,164,165] |
Name of initiative: Healthy Food Strategy, vision 2030 [159] Year: 2018 Leadership: Led by the government (SFDA) Approach: Voluntary for all food categories SFDA.FD 42 “Traffic light labeling” [166,167]
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Name of initiative: Healthy Food Strategy, vision 2030 [159] Promoting healthy life style in work environment [168] Year: 2018 Leadership: Led by the government (SFDA) Approach: Voluntary; procurement policy and education Setting: Workplace, schools, and hospitals [121] |
| Kuwait | Name of initiative: Kuwaitis lower blood pressure by reducing salt in bread [62] Year: 2013 Leadership: Led by the government (MOH), in partnership with Kuwait Flour Mills and Bakeries Co (KFMB) Approach: Voluntary—implementation of a 10% reduction of salt in pita bread, which was achieved in March 2013, followed by another 10% reduction 6 months later in August 2013. The reduction included other white and whole wheat bread varieties [61] Revision of salt standard for cheese [144,148] Name of initiative: Strategy to promote and support nutrition in school children (6–18 years old) Year: 2017 Leadership: Led by the government—Community Nutrition Promotion Sector (CNPS) of the Public Authority for Food and Nutrition (PAFN) Approach: Mandatory: 6 corn and potato crisp companies were targeted Target of salt content ≤ 1.5 g/100 g [61] |
Name of initiative: The role of Administration of Food and Nutrition MOH in controlling and prevention of non-communicable diseases in Kuwait Year: 2021 Leadership: Led by the government (Food and Nutrition Administration (FNA) on behalf of the Kuwait MOH)), in cooperation with Patient Helping Fund Society (PHFS) Approach: Mandatory- Apply the traffic light system on food items sold in governmental hospital cafeterias and canteens). Revision of hospital menus to decrease the levels of salt [169] |
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| Lebanon | Name of initiative: Lebanese Action on Sodium and Health (LASH) Year: 2012 Leadership: Led by academia in collaboration with the government Approach: Voluntary—assesses intake and sources of salt; assesses baseline salt knowledge and improved knowledge; collaborating with the Ministry of Industry and MOH to develop national salt standards in bread [144,170]. Legislation on salt reduction should have been proposed to concerned members of Parliament) [171] |
Name of initiative: Lebanese Action on Sodium and Health (LASH) Year: 2012 Leadership: Led by academia in collaboration with the government Approach: Aims to partner with a communications company to develop and launch a national salt reduction campaign in order to raise awareness on salt hazards and empower consumers to make better dietary choices [170] |
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| Morocco | Name of initiative: Reduction of salt content in food products Year: 2015 Leadership: Led by the government (MOH) [172] Voluntary for bread (No further details were identified) |
Name of initiative: Salt awareness campaign for bakers Year: 2014 Leadership: Led by the government Approach: Awareness campaign for bakers (around 300 bakeries) in Grand Casablanca region; 70% committed to implement reduction [144,147,148] Name of initiative: Reduction of salt intake via campaigns Year: 2015 Leadership: Led by the government (MOH) Approach: Awareness campaign [172] |
Name of initiative: Moroccan Nutrition Program and action plan 2017–2021 Year: NA Leadership: Led by the government Approach: Mandatory—FOP Nutrition logos, Nutri-Score (planned) [167] |
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| Oman | Name of initiative: Omani Standard for Bread [173] Year: 2019 Leadership: Led by the government (MOCI) Approach: The reduction of 10% of salt content started, as voluntary, in late 2015 and it was followed by another 10% to a total of 20% in the main three bakeries supplying most of the bread in the country [174,175] It became mandatory as of May 2019: 0.5% (0.5 g of salt in 100 g of bread) for flat bread (Arabic bread) [175] For other kinds of bread such as sliced bread or French bread: 1% (1 g of salt in 100 g of bread) [175] 30% reduction of salt in food products (planned) [144,175,176] |
Name of initiative: Campaign for reduction of Salt consumption Year: Planned for 2021–2022 Leadership: Led by the government and NGOs Approach: Social marketing campaigns, TV advertising, and events (planned) (Information provided by NFP) Name of initiative: World Salt Awareness Week Year: 2018 Leadership: Led by the government (MOH, Nutrition department) Approach: In line with the world’s celebration of the World Salt Awareness Week, awareness activities are organized during the 12th to the 18th of March [177] |
Name of initiative: NA Year: 2016 Leadership: Led by the government (MOH) Approach: Limit the availability of high salt items Setting: Schools (not adopted yet) [178] |
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| Palestine | Name of initiative: National Health Strategy, 2021–2023 Year: 2019 Leadership: Led by the government (MOH) Approach: Food categories reformulated: gradual reduction of salt content in bread—mandatory; Targets set by year: 2019—0.9 g/100 g, 2021—0.8 g/100 g, 2022—0.7 g/100 g, 2023—0.6 g/100 g [179] |
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| Qatar | Name of initiative: WHO Salt Reduction in Bread Initiative Year: 2013 Leadership: Led by the government (MOPH) (part of Nutrition & Physical Activity Action Plan 2011–2016) [180] Approach: A 20% salt reduction in bread has already been initiated in the main national bakery (Mesaieed Bakery or Qbake). This reduction has also been achieved in other main bakeries of the country [92,144,148,181]. The aim is to reduce salt content in bread samples that contain more than 0.8% of salt [148] Targets set for bread are mandatory Name of initiative: Initiative to reduce fat, sugar, and salt consumption in Qatar Year: 2019 Leadership: Led by the government (MOPH) Approach: Approach done through meetings with the food industry to set voluntary commitments to fat, salt, and sugar reduction. Targets for salt levels in foods, and (Information provided by NFP) |
Name of initiative: Food and Beverage Labelling and Calories Count Initiative at Restaurants and Coffee Shops Year: 2018 Leadership: Led by the government (MOPH and MOCI) Approach: Social marketing (e.g., campaigns, meetings with food industries, press releases, events (Information provided by NFP) Name of initiative: Salt Awareness Week (annually) Leadership: Led by the government (MOPH) Approach: Social marketing (e.g., campaigns, TV advertising (conducted TV and radio interviews), events (Information provided by NFP) Name of initiative: Initiative to reduce fat, sugar and salt consumption in Qatar Year: 2019 Leadership: Led by the government (MOPH) Approach: Social marketing (e.g., campaigns, TV advertising (conducted TV and radio interviews), events (Information provided by NFP) |
Name of initiative: Food & Beverage Guidelines; School Canteen Guidelines for Cafeterias and Vending Machines; Educational sessions in schools and workplaces Year: Ongoing Leadership: Led by the government (MOPH) Approach: Education, guidelines Setting: School, hospital, workplace, and public places such as grocery stores and shopping malls (Information provided by NFP) |
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| Tunisia | Name of initiative: Salt reduction program Year: 2015 Leadership: Led by the government Approach: Salt reduction program has already started in Bizerte city with the 22 bakeries; the program aims to progressively reduce the salt content of bread by 30%, voluntarily [144,147,182]. This is considered a pilot phase of the national action plan Name of initiative: Proposed reformulation of food products to contain less salt Year: 2018 Leadership: Led by the government (MOH) [86] (planned) |
Name of initiative: Reducing salt intake and helping consumers make healthier choices that include less salt intakes Year: 2012 Leadership: Led by the government (MOH) Approach: NA [183] Name of initiative: Media campaigns to promote change in the intake of salt Year: 2018 Leadership: Led by the government (MOH) Approach: Not adopted [86] |
Name of initiative: NA Year: 2018 Leadership: Led by the government (MOH) Approach: Mandatory—Recommend having salt content on the FOP (planned) [86,167,184]. |
Name of initiative: NA Year: 2018 Leadership: Led by the government (MOH) Approach: Create supportive environments in public places by offering low-salt options Setting: Public places, schools, workplaces (not adopted yet) [86] |
| UAE | Name of initiative: Reformulate food products (National Action Plan) Year: 2017 Leadership: Led by the government (MOHAP) Approach: Voluntary—reformulate breads to have less than 0.5% salt content and reduce salt levels in other food products such as pickles, cheeses, fast foods, snacks and other processed food (National Action Plan) (MOHAP Task Force on Reduction of Salt already established) [185] |
Name of the initiative: Reduction of salt intake by 30% (National Action Plan) Year: 2017 Leadership: Led by the government (MOHAP) Approach: Recommendations for media campaigns and programs to spread awareness in the population (including nutrition labelling) and food industries, catering businesses including restaurants cafes, kiosk etc. (MOHAP Task Force on Reduction of Salt already established) [185,186] Name of initiative: Exclude salt from your food menu Year: 2019 Leadership: Led by the government (MOHAP) Approach: Instagram posts about high, medium and low salt foods [187] Name of initiative: Pay attention to the dangers of excessive salt intake! Year: 2018 Leadership: Led by the government (MOHAP) Approach: Instagram posts about food preparation tips to decrease salt [188] |
Name of initiative: NA Year: 2020 Leadership: Led by the government Approach: Voluntary—traffic light labelling (Planned)—to become mandatory as of 2022 [167] |
Name of initiative: Healthy recipes for school lunch bag Year: 2019 Leadership: Led by government Approach: Voluntary Setting: Schools [123] |
Abbreviations: EMR: Eastern Mediterranean Region; FOP: front of pack; KSA: Kingdom of Saudi Arabia; MOCI: Ministry of Commerce and Industry; MOH: Ministry of Health; MOHAP: Ministry of Health and Prevention; MOPH: Ministry of Public Health; NA: not available; NFP: nutrition focal point; NGO: non-governmental organization; SFDA: Saudi Food and Drug Authority; UAE: United Arab Emirates; WHO: World Health Organization.