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Abstract Background Prominent product placement is a core promotional tactic in retail food environments. How this practice has been adapted for online supermarkets, and the extent to which it is applied to healthier and less healthy food products in this setting, is largely unknown. We aimed to investigate placement-type promotions of food products in Australian online supermarkets. Methods We developed a new method to assess placement promotions and applied it to the online stores of the two largest supermarket retailers in Australia. Each online store was audited across six ‘locations’ (input prior to data collection), including a randomly selected high socio-economic position area and low socio-economic position area from each of the three largest Australian cities. The names, page locations and type of placement strategy of promoted food products were captured, with product healthiness assessed using the Health Star Rating (HSR) nutrient profiling system. Descriptive statistics summarised the page locations of promoted products and the placement strategies used to promote them, and chi-squared tests applied to compare product healthiness by retailer and socio-economic position. Results We recorded 12,152 food products promoted through placement strategies, 99% of which were eligible for a HSR. Overall, 44% of products promoted through placement strategies were unhealthy. Cross-promotions and recommendations was the most common strategy recorded overall (55.9% of all strategies), and advertisements and site content was the strategy most likely to promote unhealthy products (53.7% of products unhealthy). One retailer was more likely to promote unhealthy products (46% v 43%, p = 0.004) and unhealthy products were more likely to be promoted in more disadvantaged than less disadvantaged locations (45% vs 43%, p = 0.05), though the magnitudes of difference were small. Conclusions A considerable number of unhealthy products are likely presented to online grocery shoppers in Australia. Public health policies targeting unhealthy food promotions may need to be updated, including with consideration of the different ways that products can be prominently displayed online, to avoid exacerbating risks of diet-related disease and health inequalities. Our novel methodology could be used for ongoing monitoring of online supermarkets in Australia and elsewhere to inform such policies.

Background: Potassium-enriched salt is a proven dietary intervention for reducing risk of stroke, cardiovascular disease, and premature mortality when used instead of regular table salt. Potassium-enriched salt products are available globally, but the on-pack health claims, product features, and instructions for use are diverse. Objectives: The objective of this study was to summarize the label features of potassium-enriched salt products available worldwide. Methods: A content analysis was conducted on the labels of potassium-enriched salt products available for sale in May 2023. Potassium-enriched salt products were identified through a systematic search of literature, major online shopping websites, and Google using similar keywords such as “salt substitute” or “low sodium salt.” Information on product labels was coded relating to health claims, product features, and instructions for use, and were quantitatively summarized. Results: A total of 117 potential potassium-enriched salt products were identified, with 83 included in the final analysis after excluding products containing no sodium (n = 15), no potassium (n = 5), or that were duplicates (n = 14). There were 23 (28%) products with on-pack claims for health benefits and 36 (43%) with health warnings. Twenty-five (30%) of product labels included descriptions of other product features such as taste and potassium content, and 36 (43%) had instructions for use. Conclusions: There was large variability in the label features of potassium-enriched salt products identified in this study. Most product labels made no health-related statements, but among those that did, warnings occurred more frequently than statements of health benefits. The diversity in labeling may cause confusion among consumers, and standardized, evidence-based labeling should be developed.

Abstract Background Food product labelling can support consumer decision-making. Several food product labels (nutrition information panels (NIPs), ingredients lists, allergen declarations and country-of-origin) are mandated for physical product packaging in Australia, with a voluntary front-of-pack nutrition labelling system, Health Star Ratings (HSRs), also available. However, labelling requirements are not explicitly extended to online settings and the extent to which this information is available in these increasingly important food environments has not been assessed. Methods Data from all individual food product pages was collected from the online stores of the two dominant supermarket retailers in Australia using automated web scraping in April–May 2022 (n = 22,077 products collected). We assessed the proportion of pages displaying NIPs, ingredients, allergens, country-of-origin and HSRs after excluding products ineligible to display the respective label. We also assessed whether HSRs were differentially available for higher- (healthier) and lower-scoring (less healthy) products, with HSR scores drawn from a comprehensive Australian food composition database, FoodSwitch. A manual inspection of randomly selected product pages (n = 100 for each label type per supermarket), drawn from products displaying the relevant label, was conducted to assess whether the labels were immediately visible to users (i.e. without scrolling or clicking). Differences in labelling prevalence and visibility were compared using chi-squared tests. Results Across both supermarkets, country-of-origin labelling was almost complete (displayed on 93% of food product pages), but NIPs (49%), ingredients (34%) and allergens (53%) were less frequently displayed. HSRs were infrequently displayed (14% across both supermarkets) and more likely to be applied to higher-scoring products (22% on products with ≥ 3.5HSR v 0.4% on products with

Abstract Objective: In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. Design: Repeated cross-sectional surveys were completed at baseline (2010–2013) and follow-up (2018–2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. Setting: Victoria, Australia. Participants: Children aged 4–12 years Results: Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. Conclusion: These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children’s salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Abstract Objective: Switching regular salt (sodium chloride) to salt enriched with potassium chloride (25 % potassium chloride, 75 % sodium chloride) has been shown to reduce blood pressure and the risk of cardiovascular diseases. We sought to define the potential for the current production of sodium chloride and potassium chloride to support a global switch to the use of potassium-enriched salt. Design: We summarised data from geological surveys, government reports and trade organisations describing the global production and supply of sodium chloride and potash (the primary source of potassium chloride) and compared this to potential requirements for potassium-enriched salt. Setting: Global. Participants: Not applicable. Results: Approximately 280 million tonnes of sodium chloride were produced in 2020 with China and the USA the main producers. Global production of potash from which potassium chloride is extracted was about forty-four million tonnes with Canada, Belarus, Russia and China providing 77 % of the world’s supply. There were forty-eight countries in which potassium-enriched salt is currently marketed with seventy-nine different brands identified. Allowing for loss of salt between manufacture and consumption, a full global switch from regular salt to potassium-enriched salt would require about 9·7 million tonnes of sodium chloride to be replaced with 9·7 million tonnes of potassium chloride annually. Conclusions: Significant upscaling of the production of potassium chloride and the capacity of companies able to manufacture potassium-enriched salt, as well as a robust business case for the switch to potassium chloride, would be required.

Abstract Objective: To understand the extent to which national salt reduction strategies in Malaysia and Mongolia were implemented and achieving their intended outcomes. Design: Multiple methods process evaluations conducted at the mid-point of strategy implementation, guided by theoretical frameworks. Setting: Malaysia (2018–2019) and Mongolia (2020–2021). Participants: Desk-based reviews of related documents, interviews with key stakeholders (n 12 Malaysia, n 10 Mongolia), focus group discussions with health professionals in Malaysia (n 43) and health provider surveys in Mongolia (n 12). Results: Both countries generated high-quality local evidence about salt intake and levels in foods and culturally specific education resources. In Malaysia, education and reformulation activities were delivered with moderate dose (quantity) but reach among the population was low. Within 5 years, Mongolia implemented education among schools, health professionals and food producers on salt reduction with high reach, but with moderate dose (quantity) and reach among the general population. Both countries faced challenges in implementing legislative interventions (mandatory salt labelling and salt limits in packaged foods) and both could improve the scaling up of their reformulation and education activities. Conclusions: In the first half of Malaysia’s and Mongolia’s strategies, both countries generated necessary evidence and education materials, mobilised health professionals to deliver salt reduction education and achieved small-scale reformulation in foods. Both subsequently should focus on implementing regulatory policies and achieving population-wide reach and impact. Process evaluations of existing salt reduction strategies can help strengthen intervention delivery, aiding achievement of WHO’s 30 % reduction in salt intake by 2025 target.

Abstract Background The Victorian Salt Reduction Partnership (VSRP) implemented a media advocacy strategy (intervention) to stimulate food manufacturers to reduce sodium levels across targeted Australian packaged foods between 2017 and 2019. This study assessed changes in sodium levels of targeted and non-targeted packaged foods during the intervention (2017 to 2019) compared to before the intervention (2014 to 2016) in Australia. Methods Annually collected branded-food composition data from 2014 to 2019 were used. Interrupted time series analyses was conducted to compare the trend in sodium levels in packaged foods during the intervention (2017–2019) to the trend in the pre-intervention period (2014–2016). The difference between these trends was derived to estimate the effect of the intervention. Results A total of 90,807 products were included in the analysis, of which 14,743 were targeted by the intervention. The difference in before and during intervention trends between targeted and non-targeted food categories was 2.59 mg/100 g (95% CI: -13.88 to 19.06). There was a difference in the pre-intervention slope (2014, 2015, 2016) and intervention slope (2017, 2018, 2019) for four of 17 targeted food categories. There was a decrease in sodium levels (mg/100 g) in one food category: frozen ready meals (-13.47; 95% CI: -25.40 to -1.53), and an increase in three categories: flat bread (20.46; 95% CI: 9.11 to 31.81), plain dry biscuits (24.53; 95% CI: 5.87 to 43.19), and bacon (44.54; 95% CI: 6.36 to 82.72). For the other 13 targeted categories, the difference in slopes crossed the line of null effect. Conclusions The VSRP’s media advocacy strategy did not result in a meaningful reduction in sodium levels of targeted packaged food products during the intervention years compared to trends in sodium levels before the intervention. Our study suggests media advocacy activities highlighting the differences in sodium levels in packaged food products and industry meetings alone are not sufficient to lower average sodium levels in packaged foods in the absence of government leadership and measurable sodium targets.

Objectives: Some geographic regions in high-income countries (HIC), including Australia, have poor healthy food access and a high burden of diet-related chronic disease. Scalable and sustainable strategies to strengthen community food systems have the potential to address these inequities. To inform future interventions in regions with poor healthy food access in Sydney, Australia, and beyond, we systematically reviewed randomised controlled trials of community-based food access interventions in HIC, to identify effects on dietary behaviours and health outcomes. Methods: Four electronic databases were searched. Studies involving community-based healthy food access strategies (solely or combined with education/behaviour change) and measuring effects on dietary behaviours and/or health outcomes were identified. Data on dietary behaviours, health outcomes and intervention descriptions were extracted, and the risk of bias was assessed. Results: Seven studies met inclusion criteria, with most conducted in the US (n = 6). Intervention strategies included food pantry-based interventions (n = 2), mobile produce markets (n = 2) and community farms (n = 3). Most interventions (n = 6, 85%) incorporated educational and/or behavioural change aspects. All studies measured fruit and vegetable (F&V) intake, with nearly all (n =6, 85%) reporting significant beneficial effects. Conclusion: Preliminary evidence in our synthesis demonstrates that multicomponent community-based food system interventions promise to improve F&V intake in regions of HICs. Recommendations for improving future evaluations are identified to build evidence for policymakers and urban planners to enact upstream and downstream strategies to strengthen community healthy food, particularly in geographic regions with the greatest health inequities.

Abstract Background Monitoring salt consumption in children is essential for informing and implementing public health interventions to reduce children’s salt intake. However, collection of 24-hour urines, considered as the most reliable approach, can be especially challenging to school children. This study aimed to assess the agreement between 24-hour urine (24hrU) and 24-hour food recall (24hrFR) in: (1) estimating salt intake in children; (2) classifying salt intakes above the recommended upper level set for children, and; (3) estimating change in mean salt intake over time. Methods This study utilised data from two cross-sectional surveys of school children aged 8 to 12 years living in the state of Victoria, Australia. A single 24hrU and 24hrFR were collected from each participant. Suspected inaccurate urine collections and implausible energy intakes were excluded based on pre-defined criteria. The agreement between the two methods was assessed using Bland-Altman methodology, the intraclass correlation coefficient (ICC), and the kappa statistic. The difference between the measured change in salt intake over time using 24hrU and 24hrFR was derived using mixed effects linear regression analysis. Results A total of 588 participants provided a 24hrU and 24hrFR. Overall, there was no meaningful difference in mean estimated salt intake between the two methods (− 0.2 g/day, 95% CI − 0.5 to 0.1). The Bland-Altman plot showed wide 95% limits of agreement (− 7.2 to 6.8). The ICC between the two methods was 0.13 (95% CI 0.05 to 0.21). There was poor interrater reliability in terms of classifying salt intake above the recommended upper level for children, with an observed agreement of 63% and kappa statistic of 0.11. The change in mean salt intake over time was 0.2 g/day (− 0.4 to 0.7) based on 24hrU, and 0.5 g/day (− 0.0 to 1.1) based on 24hrFR, with a difference-in-differences of 0.4 g/day (− 0.3 to 1.1). Conclusions 24hrFR appears to provide a reasonable estimate of mean salt intake as measured by 24hrU in Australian school children. However, similar to previous observations in adults, and of studies exploring other alternative methods for estimating salt intake, 24hrFR is a poor predictor of individual-level salt intake in children.

Abstract Background One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji. Methods To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost–consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact. Discussion By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

BackgroundTo reduce excess dietary sodium consumption, Nigeria's 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders' knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions.MethodsFrom January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions.ResultsMost stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum.ConclusionWe found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

Abstract Background Countries around the world are putting in place sugar reformulation targets for packaged foods to reduce excess sugar consumption. The Australian government released its voluntary sugar reformulation targets for nine food categories in 2020. We estimated the potential impact of these targets on household sugar purchases and examined differences by income. For comparison, we also modelled the potential impact of the UK sugar reduction targets on per capita sugar purchases as the UK has one of the most comprehensive sugar reduction strategies in the world. Methods Grocery purchase data from a nationally representative consumer panel (n=7,188) in Australia was linked with a large database (FoodSwitch) with product-specific sugar content information for packaged foods (n=25,261); both datasets were collected in 2018. Potential reductions in per capita sugar purchases were calculated overall and by food category. Differences in sugar reduction across income level were assessed by analysis of variance. Results In 2018, the total sugar acquired from packaged food and beverage purchases consumed at-home was 56.1 g/day per capita. Australia’s voluntary reformulation targets for sugar covered 2,471/25,261 (9.8%) unique products in the FoodSwitch dataset. Under the scenario that all food companies adhered to the voluntary targets, sugar purchases were estimated to be reduced by 0.9 g/day per capita, which represents a 1.5% reduction in sugar purchased from packaged foods. However, if Australia adopted the UK targets, over twice as many products would be covered (n=4,667), and this would result in a more than four times greater reduction in sugar purchases (4.1 g/day per capita). It was also estimated that if all food companies complied with Australia’s voluntary sugar targets, reductions to sugar would be slightly greater in low-income households compared with high-income households by 0.3 g/day (95%CI 0.2 - 0.4 g/day, p

Abstract Background Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP’s advocacy strategy in achieving policy change. Methods Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the Kotter Plus 10-step public health advocacy evaluation framework was used to guide data extraction, analysis, and synthesis. Results A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction programme. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established, but communication of the vision to decision-makers was lacking, which reduced the impact of the programme as decision-makers were not provided with a clear incentive for policy change. As a result, while programme outputs were achieved, these did not translate to achieving broader strategic goals during a limited-term intervention in a political climate unconcerned with salt. Conclusions The Kotter Plus 10-step framework was a useful tool for evaluating the success of the VSRP advocacy strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within partnerships and to decision-makers, to better influence policy and improve public health impact.

Abstract Background Interventions to reduce population salt intake are feasible and cost-effective. The Victorian Salt Reduction Partnership implemented a complex, multi-faceted salt reduction intervention between 2014 and 2020 in the Australian state of Victoria. This study aimed to understand stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership. Methods Semi-structured interviews were conducted with Partnership and food industry stakeholders. The Consolidated Framework for Implementation Research was adapted for the Partnership intervention and used to guide the qualitative analysis. Results Fourteen Partnership and seven food industry stakeholders were interviewed. The Partnership was viewed as essential for intervention planning and decision-making and an enabler for intervention delivery. The goals of capacity building and collaborative action were perceived to have been achieved. The implementation team executed intended intervention activities and outputs, with some adaptations to strategy. Barriers and enablers to implementation were identified by interviewees, such as compatibility of individual, organisational and Partnership values and building positive relationships between the Partnership and food industry, respectively. Legal, political, social, environmental, technological and economic factors affecting intervention design, delivery and outcomes were identified. Conclusions Establishing a Partnership with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Monitoring and evaluating implementation informed strategy adaptations, which allowed optimisation of Partnership strategy. The importance of developing strong communication networks between strategic and implementation-levels was a key lesson.

Abstract Background Dietary sodium reduction is recommended to reduce the burden of cardiovascular disease. In Vietnam food products including salt, fish sauce and bot canh contribute to ~ 70% of dietary sodium intake. Reduced sodium versions of these products can be produced by replacing some of the sodium chloride with potassium chloride. We aimed to assess the cost-effectiveness of three alternative approaches to introducing reduced sodium products onto the market with a view to lowering population sodium intake in Vietnam. Methods The three salt substitution strategies included voluntary, subsidised and regulatory approaches targeting salt, fish sauce and bot canh products. Costs were modelled using the WHO-CHOICE methodology. A Markov cohort model was developed to evaluate the cost-effectiveness of each strategy versus no intervention from the government perspective. The model linked each intervention strategy to assumed changes in levels of sodium intake and then to systolic blood pressure. Changes in SBP were linked to a probability of ischaemic heart disease or stroke. The model followed people over their lifetime to assess average costs and quality adjusted life years (QALYs) gained for each strategy. Results The voluntary salt substitution strategy was assumed to require no investment by government. Following ramp up (years 6+), the average annual costs for the subsidised and regulatory strategies were 21,808,968,902 ₫ (US$ 977,354) and 12,949,953,247 ₫ (US$ 580,410) respectively. Relative to no intervention, all three salt substitution strategies were found to be cost-effective. Cost savings were driven by reductions in strokes (32,595; 768,384; 2,366,480) and ischaemic heart disease (IHD) events (22,830; 537,157; 1,648,590) for the voluntary, subsidised & regulatory strategies, respectively. The voluntary strategy was least cost-effective (− 3445 ₫ US$ -0.15; 0.009 QALYs gained) followed by the subsidised strategy (− 43,189 ₫ US$ -1.86; 0.022 QALYs gained) and the regulatory strategy delivered the highest cost savings and health gains (− 243,530 ₫ US$ -10.49; 0.074 QALYs gained). Conclusion This research shows that all three modelled salt substitution strategies would be good value for money relative to no intervention in Vietnam. The subsidised alternative would require the highest level of government investment; however the implementation costs will be exceeded by healthcare savings assuming a reasonable time horizon is considered.

Reducing salt intake is one of the most cost-effective interventions to improve population health due to the subsequent reductions in blood pressure. Countries are introducing programs to lower salt consumption. Such programs usually focus on reducing salt in packaged foods and meals alongside campaigns to change consumer behavior. Thus, this paper provides an overview of the rationale for and evidence supporting the use of salt substitutes. Cur­rent approaches to salt reduction are insufficient, and more innovative solutions need to be identified. There is good evidence that salt substitutes, where some of the sodium is replaced with potassium, are effective to lower sodium total intake. The main challenge is to understand the pathways to market for salt substitutes. How do we implement programs to promote salt substitutes in different countries? What levels of government intervention are required? With more research and government investment, salt substitutes could be a game changer for increasing the impact of strategies to reduce population salt intake.

Abstract Background Australians are consuming almost double the recommended maximum salt intake. The Victorian Salt Reduction Partnership was established to coordinate efforts to reduce salt intake in the state of Victoria. As part of an intervention strategy, media advocacy strategies were used to raise public awareness and stimulate industry and government action on salt reduction. This study aimed to evaluate the Victorian Salt Reduction Partnership’s media advocacy activities by determining the extent to which activities contributed to the overall strategy aims and the effectiveness of the activities in gaining media and industry engagement. Methods A framework for evaluating media advocacy strategies used in complex public health interventions was used to guide this evaluation. Media advocacy activities were monitored and documented throughout the intervention period. A content analysis of media release press statements was performed. Indicators of media coverage (media items, cumulative audience reach, advertising space rate) and food industry engagement (number of meetings, number and type of follow up actions) were tracked. Results Six media releases were issued between March 2017 and November 2018 on different processed food categories including breads, cooking sauces, ready meals, dips and crackers, processed meats and Asian-style sauces. Three main themes were identified in the qualitative analysis of the press statements: general information on salt and health, salt levels in foods, and calls to action for consumers, industry and/or government. These themes were aligned with the overall intervention strategy. Media items (print and online news, radio and TV) generated by each release ranged from 36 to 274, and cumulative audience reach (opportunities to see) ranged from 2.3 to 7.5 million Australians per release. One to three food manufacturers were met with per media release. Conclusions Disseminating sodium-monitoring data through media releases can be used as a tool to gain access to the media and reach consumers with salt reduction messages, and to engage food manufacturers in discussions about salt reduction. Characteristics of media advocacy activities, including alignment with the overall strategy, and external factors outside the of control of the program implementers, can influence media and industry engagement. When planning future nutrition interventions that include media advocacy activities, internal and external factors impacting outcomes, should be considered, documented and evaluated.

Abstract Background The Australian federal government will soon release voluntary sodium reduction targets for 30 packaged food categories through the Healthy Food Partnership. Previous assessments of voluntary targets show variable industry engagement, and little is known about the extent that major food companies and their products contribute to dietary sodium purchases among Australian households. Methods The aim of this cross-sectional study was to identify the relative contribution that food companies and their products made to Australian household sodium purchases in 2018, and to examine differences in sodium purchases by household income level. We used 1 year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with database that contains product-specific sodium content for packaged foods and beverages (FoodSwitch). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Differences in per capita sodium purchases by income levels were assessed by 1-factor ANOVA. All analyses were modelled to the Australian population in 2018 using sample weights. Results Sodium data were available from 7188 households who purchased 26,728 unique products and purchased just under 7.5 million food product units. Out of 1329 food companies, the top 10 accounted for 35% of unique products and contributed to 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12–15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, particularly driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased significantly more sodium from packaged products than high-income households per capita (452 mg/d, 95%CI: 363-540 mg/d, P

Abstract The September 2019 United Nations’ High-Level Meeting renewed political commitments to invest in universal health coverage by strengthening health systems, programmes and policies to achieve ‘health for all’. This Political Declaration is relevant to addressing the increasing global burden of non-communicable diseases, but how can evidence-based programmes and policies be meaningfully implemented and integrated into local contexts? In this Commentary, we describe how the process of contextualisation and associated tools, such as ecological frameworks, implementation research frameworks, health system indicators, effective system strengthening strategies and evidence mapping databases with priority-setting, can enhance the implementation and integration of non-communicable disease prevention and control policies and programmes. Examples across health platforms include (1) population approaches to reducing excess sodium intake, (2) fixed-dose combination therapy for cardiovascular disease prevention and control, and (3) health systems strengthening for improving the quality and safety of cardiovascular care. Contextualisation is needed to transfer evidence into locally relevant and impactful policies and programmes. The systematic and comprehensive use of contextualisation tools leverages key implementation research principles to achieve ‘health for all’.

Despite growing evidence of increased saturated and trans fat contents in street foods, little is known about their fatty acid (FA) compositions. This study aimed to analyse the saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), and trans fatty acids (TFAs) content of 70 selected and most commonly available street foods in Malaysia. The street foods were categorised into main meals, snacks, and desserts. TFAs were not detected in any of the street foods. Descriptively, all three categories mainly contained SFAs, followed by MUFAs, and PUFAs. However, the one-way ANOVA testing showed that the differences between each category were insignificant (p > 0.05), and each FA was not significantly different (p > 0.05) from one to another. Nearly half of the deep-fried street foods contained medium to high SFAs content (1.7 g/100 g–24.3 g/100 g), while the MUFAs were also high (32.0–44.4%). The Chi-square test of association showed that the type of preparation methods (low or high fat) used was significantly associated (p < 0.05) with the number of SFAs. These findings provide valuable information about fat composition in local street foods for the Malaysian Food Composition Database and highlight the urgency to improve nutritional composition.

Background The Australian Government recently established sodium targets for packaged foods to encourage voluntary reformulation to reduce population sodium consumption and related diseases. We modeled the health impact of Australia’s sodium reformulation targets and additional likely health gains if more ambitious, yet feasible sodium targets had been adopted instead. Methods and findings Using comparative risk assessment models, we estimated the averted deaths, incidence, and disability-adjusted life years (DALYs) from cardiovascular disease (CVD), chronic kidney disease (CKD) and stomach cancer after implementation of (a) Australia’s sodium targets (overall and by individual companies); (b) United Kingdom’s targets (that covers more product categories); and (c) an optimistic scenario (sales-weighted 25th percentile sodium content for each food category included in the UK program). We used nationally representative data to estimate pre- and post-intervention sodium intake, and other key data sources from the Global Burden of Disease study. Full compliance with the Australian government’s sodium targets could prevent approximately 510 deaths/year (95% UI, 335 to 757), corresponding to about 1% of CVD, CKD, and stomach cancer deaths, and prevent some 1,920 (1,274 to 2,600) new cases and 7,240 (5,138 to 10,008) DALYs/year attributable to these diseases. Over half (59%) of deaths prevented is attributed to reformulation by 5 market-dominant companies. Compliance with the UK and optimistic scenario could avert approximately an additional 660 (207 to 1,227) and 1,070 (511 to 1,856) deaths/year, respectively, compared to Australia’s targets. The main limitation of this study (like other modeling studies) is that it does not prove that sodium reformulation programs will prevent deaths and disease events; rather, it provides the best quantitative estimates and the corresponding uncertainty of the potential effect of the different programs to guide the design of policies. Conclusions There is significant potential to strengthen Australia’s sodium reformulation targets to improve its health impact. Promoting compliance by market-dominant food companies will be critical to achieving the potential health gains. Kathy Trieu and colleagues model the estimated health impact of sodium reformulation targets in Australia. Author summary Why was this study done? High sodium intake increases blood pressure and the risk of heart disease, chronic kidney disease (CKD), and stomach cancer. Almost all adults in Australia and worldwide exceed sodium intake recommendations. To help reduce population sodium intakes, the Australian Government recently established sodium targets for packaged foods to encourage voluntary reformulation. However, the potential health gains of these targets are not known. What did the researchers do and find? We modeled the potential health gains that could be achieved if all food companies met Australia’s sodium targets and what additional health gains could be achieved if Australia adopted more ambitious targets. Using mathematical models, reductions in population sodium intake after implementation of sodium targets were calculated and translated into expected changes in blood pressure and health gains related to heart disease, CKD, and stomach cancer. Full compliance with Australia’s sodium targets could prevent approximately 510 deaths/year. Over half of these deaths could be prevented by just 5 food companies complying with the targets. If Australia adopted the sodium targets already implemented in the United Kingdom or a more ambitious, yet feasible set of targets, an additional 660 and 1,070 deaths/year, respectively, could be averted. What do these findings mean? This study demonstrates that national sodium reformulation targets could be an effective strategy to prevent death and disability associated with heart disease, CKD, and stomach cancer. Australia’s sodium reformulation targets could achieve greater public health benefits if these targets were mandatory, targeted more food categories, and included more stringent targets. To maximize the potential of Australia’s current sodium targets, promoting full compliance across dominant food companies could help to achieve health gains.

BackgroundSuboptimal diets are a leading risk factor for death and disability. Nutrition labelling is a potential method to encourage consumers to improve dietary behaviour. This systematic review and network meta-analysis (NMA) summarises evidence on the impact of colour-coded interpretive labels and warning labels on changing consumers' purchasing behaviour.Methods and findingsWe conducted a literature review of peer-reviewed articles published between 1 January 1990 and 24 May 2021 in PubMed, Embase via Ovid, Cochrane Central Register of Controlled Trials, and SCOPUS. Randomised controlled trials (RCTs) and quasi-experimental studies were included for the primary outcomes (measures of changes in consumers' purchasing and consuming behaviour). A frequentist NMA method was applied to pool the results. A total of 156 studies (including 101 RCTs and 55 non-RCTs) nested in 138 articles were incorporated into the systematic review, of which 134 studies in 120 articles were eligible for meta-analysis. We found that the traffic light labelling system (TLS), nutrient warning (NW), and health warning (HW) were associated with an increased probability of selecting more healthful products (odds ratios [ORs] and 95% confidence intervals [CIs]: TLS, 1.5 [1.2, 1.87]; NW, 3.61 [2.82, 4.63]; HW, 1.65 [1.32, 2.06]). Nutri-Score (NS) and warning labels appeared effective in reducing consumers' probability of selecting less healthful products (NS, 0.66 [0.53, 0.82]; NW,0.65 [0.54, 0.77]; HW,0.64 [0.53, 0.76]). NS and NW were associated with an increased overall healthfulness (healthfulness ratings of products purchased using models such as FSAm-NPS/HCSP) by 7.9% and 26%, respectively. TLS, NS, and NW were associated with a reduced energy (total energy: TLS, -6.5%; NS, -6%; NW, -12.9%; energy per 100 g/ml: TLS, -3%; NS, -3.5%; NW, -3.8%), sodium (total sodium/salt: TLS, -6.4%; sodium/salt per 100 g/ml: NS: -7.8%), fat (total fat: NS, -15.7%; fat per 100 g/ml: TLS: -2.6%; NS: -3.2%), and total saturated fat (TLS, -12.9%; NS: -17.1%; NW: -16.3%) content of purchases. The impact of TLS, NS, and NW on purchasing behaviour could be explained by improved understanding of the nutrition information, which further elicits negative perception towards unhealthful products or positive attitudes towards healthful foods. Comparisons across label types suggested that colour-coded labels performed better in nudging consumers towards the purchase of more healthful products (NS versus NW: 1.51 [1.08, 2.11]), while warning labels have the advantage in discouraging unhealthful purchasing behaviour (NW versus TLS: 0.81 [0.67, 0.98]; HW versus TLS: 0.8 [0.63, 1]). Study limitations included high heterogeneity and inconsistency in the comparisons across different label types, limited number of real-world studies (95% were laboratory studies), and lack of long-term impact assessments.ConclusionsOur systematic review provided comprehensive evidence for the impact of colour-coded labels and warnings in nudging consumers' purchasing behaviour towards more healthful products and the underlying psychological mechanism of behavioural change. Each type of label had different attributes, which should be taken into consideration when making front-of-package nutrition labelling (FOPL) policies according to local contexts. Our study supported mandatory front-of-pack labelling policies in directing consumers' choice and encouraging the food industry to reformulate their products.Protocol registryPROSPERO (CRD42020161877).

Street food is a major source of food in middle- and low-income countries as it is highly accessible and inexpensive. However, it is usually perceived as unhealthy due to the high levels of sodium, sugar, and fat content. However, there is little analytical data on the sodium levels in the street foods of Malaysia. This study started with a survey to determine the most frequently available street foods in every state in Malaysia, followed by food sampling and the analysis of sodium (reported mg/100 g sample). Street food in the snack category contained the highest amount of sodium (433 mg), followed by main meals (336.5 mg) and desserts (168 mg). Approximately 30% of the local street food in this study was deep-fried. Snacks from processed food (8%) contained high sodium content (500–815 mg). Fried noodles and noodle soup contained the highest amount of sodium (>2000 mg sodium) based on per serving. Most main dishes that use a variety of sauces contained high amounts of sodium. These findings were recorded in the Malaysian Food Composition Database. Moreover, this study could raise awareness and serve as baseline data for future interventions on the sodium content in the street foods of Malaysia.

BackgroundWe aimed to investigate the association of serum pentadecanoic acid (15:0), a biomarker of dairy fat intake, with incident cardiovascular disease (CVD) and all-cause mortality in a Swedish cohort study. We also systematically reviewed studies of the association of dairy fat biomarkers (circulating or adipose tissue levels of 15:0, heptadecanoic acid [17:0], and trans-palmitoleic acid [t16:1n-7]) with CVD outcomes or all-cause mortality.Methods and findingsWe measured 15:0 in serum cholesterol esters at baseline in 4,150 Swedish adults (51% female, median age 60.5 years). During a median follow-up of 16.6 years, 578 incident CVD events and 676 deaths were identified using Swedish registers. In multivariable-adjusted models, higher 15:0 was associated with lower incident CVD risk in a linear dose-response manner (hazard ratio 0.75 per interquintile range; 95% confidence interval 0.61, 0.93, P = 0.009) and nonlinearly with all-cause mortality (P for nonlinearity = 0.03), with a nadir of mortality risk around median 15:0. In meta-analyses including our Swedish cohort and 17 cohort, case-cohort, or nested case-control studies, higher 15:0 and 17:0 but not t16:1n-7 were inversely associated with total CVD, with the relative risk of highest versus lowest tertile being 0.88 (0.78, 0.99), 0.86 (0.79, 0.93), and 1.01 (0.91, 1.12), respectively. Dairy fat biomarkers were not associated with all-cause mortality in meta-analyses, although there were ≤3 studies for each biomarker. Study limitations include the inability of the biomarkers to distinguish different types of dairy foods and that most studies in the meta-analyses (including our novel cohort study) only assessed biomarkers at baseline, which may increase the risk of misclassification of exposure levels.ConclusionsIn a meta-analysis of 18 observational studies including our new cohort study, higher levels of 15:0 and 17:0 were associated with lower CVD risk. Our findings support the need for clinical and experimental studies to elucidate the causality of these relationships and relevant biological mechanisms.

BackgroundRegular salt is about 100% sodium chloride. Low-sodium salts have reduced sodium chloride content, most commonly through substitution with potassium chloride. Low-sodium salts have a potential role in reducing the population's sodium intake levels and blood pressure, but their availability in the global market is unknown. ObjectiveThe aim of this study is to assess the availability, formulation, labeling, and price of low-sodium salts currently available to consumers worldwide. MethodsLow-sodium salts were identified through a systematic literature review, Google search, online shopping site searches, and inquiry of key informants. The keywords “salt substitute,” “low-sodium salt,” “potassium salt,” “mineral salt,” and “sodium reduced salt” in six official languages of the United Nations were used for the search. Information about the brand, formula, labeling, and price was extracted and analyzed. ResultsA total of 87 low-sodium salts were available in 47 out of 195 (24%) countries worldwide, including 28 high-income countries, 13 upper-middle-income countries, and 6 lower-middle-income countries. The proportion of sodium chloride varied from 0% (sodium-free) to 88% (as percent of weight; regular salt is 100% sodium chloride). Potassium chloride was the most frequent component with levels ranging from 0% to 100% (potassium chloride salt). A total of 43 (49%) low-sodium salts had labels with the potential health risks, and 33 (38%) had labels with the potential health benefits. The median price of low-sodium salts in high-income, upper-middle-income, and lower-middle-income countries was US $15.00/kg (IQR 6.4-22.5), US $2.70/kg (IQR 1.7-5.5), and US $2.90/kg (IQR 0.50-22.2), respectively. The price of low-sodium salts was between 1.1 and 14.6 times that of regular salts. ConclusionsLow-sodium salts are not widely available and are commonly more expensive than regular salts. Policies that promote the availability, affordability, and labeling of low-sodium salts should increase uptake, helping populations reduce blood pressure and prevent cardiovascular diseases. International Registered Report Identifier (IRRID)RR2-10.1111/jch.14054

Abstract Background There is an increasing interest in finding less costly and burdensome alternatives to measuring population-level salt intake than 24-h urine collection, such as spot urine samples. However, little is known about their usefulness in developing countries like Fiji and Samoa. The purpose of this study was to evaluate the capacity of spot urine samples to estimate mean population salt intake in Fiji and Samoa. Methods The study involved secondary analyses of urine data from cross-sectional surveys conducted in Fiji and Samoa between 2012 and 2016. Mean salt intake was estimated from spot urine samples using six equations, and compared with the measured salt intake from 24-h urine samples. Differences and agreement between the two methods were examined through paired samples t-test, intraclass correlation coefficient analysis, and Bland-Altman plots and analyses. Results A total of 414 participants from Fiji and 725 participants from Samoa were included. Unweighted mean salt intake based on 24-h urine collection was 10.58 g/day (95% CI 9.95 to 11.22) in Fiji and 7.09 g/day (95% CI 6.83 to 7.36) in Samoa. In both samples, the INTERSALT equation with potassium produced the closest salt intake estimate to the 24-h urine (difference of − 0.92 g/day, 95% CI − 1.67 to − 0.18 in the Fiji sample and + 1.53 g/day, 95% CI 1.28 to 1.77 in the Samoa sample). The presence of proportional bias was evident for all equations except for the Kawasaki equation. Conclusion These data suggest that additional studies where both 24-h urine and spot urine samples are collected are needed to further assess whether methods based on spot urine samples can be confidently used to estimate mean population salt intake in Fiji and Samoa.

Abstract Background Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD). Methods Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified. Results The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation. Conclusion This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts.

ObjectiveTo construct a whole-of-system model to inform strategies that reduce the burden of cardiovascular disease (CVD) in Australia.MethodsA system dynamics model was developed with a multidisciplinary modelling consortium. The model population comprised Australians aged 40 years and over, and the scope encompassed acute and chronic CVD as well as primary and secondary prevention. Health outcomes were CVD-related deaths and hospitalisations, and economic outcomes were the net benefit from both the healthcare system and societal perspectives. The eight strategies broadly included creating social and physical environments supportive of a healthy lifestyle, increasing the use of preventive treatments, and improving systems response to acute CVD events. The effects of strategies were estimated as relative differences to the business-as-usual between 2019-2039. Probabilistic sensitivity analysis produced uncertainty intervals of interquartile ranges (IQR).FindingsThe greatest reduction in CVD-related deaths was seen in strategies that improve systems response to acute CVD events (8.9%, IQR: 7.7-10.2%), yet they resulted in an increase in CVD-related hospitalisations due to future recurrent admissions (1.6%, IQR: 0.1-2.3%). This flow-on effect highlighted the importance of addressing underlying CVD risks. On the other hand, strategies targeting the broad environment that supports a healthy lifestyle were effective in reducing both hospitalisations (7.1%; IQR: 5.0-9.5%) and deaths (8.1% reduction; IQR: 7.1-8.9%). They also produced an economic net benefit of AU$43.3 billion (IQR: 37.7-48.7) using a societal perspective, largely driven by productivity gains. Overall, strategic planning to reduce the burden of CVD should consider the varying effects of strategies over time and beyond the health sector.

Abstract Background Evidence for recommended interventions to reduce population salt intake come from high-income countries, but it is unknown if these can be successfully replicated in low- and middle-income countries. This process evaluation investigated the reach, dose/adoption, fidelity, cost, and context of a national salt reduction program of interventions in Samoa. Methods Monitoring and Action on Salt in Samoa (MASIMA) was a pre- and post-intervention study of a government-led strategy to lower population salt intake comprising awareness campaigns, community mobilization and policy and environmental changes. Data relating to the five process evaluation dimensions were collected from routinely collected data, a post-intervention survey and stakeholder interviews. Chi-squared tests assessed differences in quantitative survey responses among groups. Thematic analysis of qualitative interview responses was undertaken and triangulated with the quantitative data. Results Awareness campaigns, school nutrition standards, and community mobilization interventions were implemented with moderate reach and fidelity. Higher than expected costs of campaigns and limited opportunity (one-off) to mobilize community leaders to disseminate salt reduction messages were key implementation challenges, which meant intervention dose was low. Environmental-level initiatives including engagement with the food industry to voluntary reduce salt in foods and the introduction of salt-related regulations were more challenging to implement within 18-months, particularly given the delay in the passing of the Food Act which provides for enforcement of regulations. Contextual factors that hindered the interventions’ mechanism of effect include the food culture, higher cost, and lower availability of healthy low-salt foods relative to unhealthy foods and salty taste preference. Conclusion Although individual and community-based interventions helped increase awareness about the importance of salt reduction in Samoa, legislative backing was needed to alter the food environment to achieve population reduction in salt intake. It was not possible to engage the food industry to lower salt in foods through a voluntary approach in Samoa’s current context, although such initiatives were successful in some high-income countries. Future individual and environmental-level interventions to reduce salt intake need to address the contextual influences of food choices. In Samoa, this means salt reduction strategies need to ensure consuming lower salt is affordable, widely available, and perceived as flavorsome.

Abstract Objective: To provide an overview of published research on the dietary intake of Aboriginal and Torres Strait Islander peoples. Methods: Peer‐reviewed literature from 1990 to October 2016 was searched to identify studies that measured the dietary intake of Australian Aboriginal and Torres Strait Islander populations. Study quality was assessed using a purposely devised quality appraisal tool. Meta‐analysis was not possible due to the heterogeneity in dietary intake assessment methods. A narrative synthesis of study findings, where key themes were compared and contrasted was completed. Results: Twenty‐five articles from twenty studies with outcome measures related to dietary intake were included. Dietary intake was assessed by electronic store sales, store turnover method, 24‐hour dietary recall, food frequency questionnaire and short questions. Consistent findings were low reported intakes of fruit and vegetables and high intakes of total sugar and energy‐dense, nutrient‐poor food and beverages. Conclusions: While differences between studies and study quality limit the generalisability of the findings, most studies suggest that the diets of Aboriginal and Torres Strait Islander peoples are inadequate. Implications for public health: A more concerted approach to understanding dietary patterns of Aboriginal and Torres Strait Islander peoples is required to inform policy and practice to improve diet and nutrition.

An amendment to this paper has been published and can be accessed via the original article.

OBJECTIVE:To summarise evidence describing the cost-effectiveness of population-based interventions targeting sodium reduction. METHODS:A systematic search of published and grey literature databases and websites was conducted using specified key words. Characteristics of identified economic evaluations were recorded, and included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS:Twenty studies met the study inclusion criteria and received a full paper review. Fourteen studies were identified as full economic evaluations in that they included both costs and benefits associated with an intervention measured against a comparator. Most studies were modelling exercises based on scenarios for achieving salt reduction and assumed effects on health outcomes. All 14 studies concluded that their specified intervention(s) targeting reductions in population sodium consumption were cost-effective, and in the majority of cases, were cost saving. Just over half the studies (8/14) were assessed as being of 'excellent' reporting quality, five studies fell into the 'very good' quality category and one into the 'good' category. All of the identified evaluations were based on modelling, whereby inputs for all the key parameters including the effect size were either drawn from published datasets, existing literature or based on expert advice. CONCLUSION:Despite a clear increase in evaluations of salt reduction programs in recent years, this review identified relatively few economic evaluations of population salt reduction interventions. None of the studies were based on actual implementation of intervention(s) and the associated collection of new empirical data. The studies universally showed that population-based salt reduction strategies are likely to be cost effective or cost saving. However, given the reliance on modelling, there is a need for the effectiveness of new interventions to be evaluated in the field using strong study designs and parallel economic evaluations.

To quantify progress with the initiation of salt reduction strategies around the world in the context of the global target to reduce population salt intake by 30% by 2025.A systematic review of the published and grey literature was supplemented by questionnaires sent to country program leaders. Core characteristics of strategies were extracted and categorised according to a pre-defined framework.A total of 75 countries now have a national salt reduction strategy, more than double the number reported in a similar review done in 2010. The majority of programs are multifaceted and include industry engagement to reformulate products (n = 61), establishment of sodium content targets for foods (39), consumer education (71), front-of-pack labelling schemes (31), taxation on high-salt foods (3) and interventions in public institutions (54). Legislative action related to salt reduction such as mandatory targets, front of pack labelling, food procurement policies and taxation have been implemented in 33 countries. 12 countries have reported reductions in population salt intake, 19 reduced salt content in foods and 6 improvements in consumer knowledge, attitudes or behaviours relating to salt.The large and increasing number of countries with salt reduction strategies in place is encouraging although activity remains limited in low- and middle-income regions. The absence of a consistent approach to implementation highlights uncertainty about the elements most important to success. Rigorous evaluation of ongoing programs and initiation of salt reduction programs, particularly in low- and middle- income countries, will be vital to achieving the targeted 30% reduction in salt intake.

Background On average, Australian adults consume 3500 mg sodium per day, almost twice the recommended maximum level of intake. The Australian government through the Healthy Food Partnership initiative has developed a voluntary reformulation programme with sodium targets for 27 food categories. We estimated the potential impact of this programme on household sodium purchases (mg/day per capita) and examined potential differences by income level. We also modelled and compared the effects of applying the existing UK reformulation programme targets in Australia.Methods This study used 1 year of grocery purchase data (2018) from a nationally representative consumer panel of Australian households (Nielsen Homescan) that was linked with a packaged food and beverage database (FoodSwitch) that contains product-specific sodium information. Potential reductions in per capita sodium purchases were calculated and differences across income level were assessed by analysis of variance. All analyses were modelled to the Australian population in 2018.Results A total of 7188 households were included in the analyses. The Healthy Food Partnership targets covered 4307/26 728 (16.1%) unique products, which represented 22.3% of all packaged foods purchased by Australian households in 2018. Under the scenario that food manufacturers complied completely with the targets, sodium purchases will be reduced by 50 mg/day per capita, equivalent to 3.5% of sodium currently purchased from packaged foods. Reductions will be greater in low-income households compared with high-income households (mean difference −7 mg/day, 95% CI −4 to −11 mg/day, p