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1、WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONWHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONWHO global report on sodium intake reductionISBN 978-92-4-006998-5(electronic version)ISBN 978-92-4-006999-2(print version)World Health Organization 2023Some rights reserved.This work is available under the Creat
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5、ny mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization(http:/www.wipo.int/amc/en/mediation/rules/).Suggested citation.WHO global report on sodium intake reduction.Geneva:World Health Organi
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8、der.The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.General disclaimers.The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO
9、 concerning the legal status of any country,territory,city or area or of its authorities,or concerning the delimitation of its frontiers or boundaries.Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement The mention of specific companies or
10、 of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned.Errors and omissions excepted,the names of proprietary products are distinguished by initial capital letters.All reasonable precautions ha
11、ve been taken by WHO to verify the information contained in this publication.However,the published material is being distributed without warranty of any kind,either expressed or implied.The responsibility for the interpretation and use of the material lies with the reader.In no event shall WHO be li
12、able for damages arising from its use.Design and layout:Alberto MarchPrinted in SwitzerlandiiiContentsAcknowledgements vAbbreviations viForeword viiExecutive summary viiiScope and purpose ixBackground 1WHO guideline:sodium intake for adults and children 2Member State commitments to the prevention an
13、d control of noncommunicable diseases 3Methods 5Implementation of sodium reduction policies and measures 6 Sodium Country Score Card 6Population dietary sodium intake 8Modelled health impact of sodium reduction policies and measures 8Results 11Implementation of sodium reduction policies and measures
14、 12National policy commitments 12Measures to reduce sodium in the food supply or encourage consumers to make healthier food choices about sodium 13Reformulation to reduce sodium content across the food supply 15Public food procurement and service policies 19Nutrition labelling 21Mass media campaigns
15、 27Marketing restrictions 29Fiscal policies 31Sodium Country Score Card 33Sodium Country Score Cards:African Region 35Sodium Country Score Cards:Region of the Americas 36Sodium Country Score Cards:Eastern Mediterranean Region 37Sodium Country Score Cards:European Region 38Sodium Country Score Cards:
16、South-East Asia Region 39Sodium Country Score Cards:Western Pacific Region 40Population dietary sodium intake 41Modelled health impact of sodium reduction policies and measures 42Impact of policies and measures on sodium intake 42Impact of policies and measures on cardiovascular disease 42The way fo
17、rward 43References 46Annexes 53Annex 1:Sodium intake,sodium country score,policies and measures in WHO Member States 54Annex 2:Details of sodium reduction policies and measures implemented around the world 70Annex 3:Overview of mandatory and voluntary measures by WHO region 87Annex 4:Overview of man
18、datory and voluntary measures by World Bank income group 90vAcknowledgements This report was developed by Ms Kaia Engesveen,Ms Allison Goldstein,Dr Mary-Anne Land and Ms Camilla Haugstveit Warren under the coordination of Dr Luz Maria De-Regil,Multisectoral Action in Food Systems Unit,Department of
19、Nutrition and Food Safety,World Health Organization(WHO).The valuable technical contributions from colleagues across WHO are recognized:Dr Ayoub Al-Jawaldeh,Dr Lorena Allemandi,Dr Hana Bekele,Dr Elaine Borghi,Dr Francesco Branca,Ms Melanie Cowan,Dr Angela De Silva,Mr Fabio Da Silva Gomes,Dr Katrin E
20、ngelhardt,Ms Eman Ibrahim,Dr Luc Ingenbleek,Dr Lucero Lopez-Perez,Ms Fabienne Maertens,Mr Eugene Mahlehla,Ms Nashwa Mansour,Dr Ricardo X.Martinez,Mr Leendert Nederveen,Dr Chizuru Nishida,Ms Pyi Pyi Phyo,Ms Leanne Riley,Dr Juliawati Untoro,Ms Laura Utemissova,Mr Stephen Whiting,Dr Kremlin Wickramasin
21、ghe and Dr Rain Yamamoto.Also recognized are the WHO Nigeria noncommunicable disease team through Dr Kelias Phiri Msyamboza and the WHO Country Office of Sri Lanka.WHO also recognizes the valuable contributions made by Ms Simone Bosch,Dr Laura Cobb,Dr Renu Garg,Ms Nicole Ide(Resolve to Save Lives)an
22、d Mr Aaron Schwid(Vital Strategies),Ms Mhairi Brown(World Action on Salt,Sugar and Health),Dr Marieke Hendriksen(WHO Collaborating Centre for Nutrition),Dr Megan E.Henry(Johns Hopkins Bloomberg School of Public Health),Dr Kathy Trieu and Professor Jacqui Webster(WHO Collaborating Centre on Populatio
23、n Salt Reduction),Professor Jason Wu(Nutrition Science Program,The George Institute for Global Health),Professor Peter Scarborough(Nuffield Department of Population Health,University of Oxford),Professor Chantal Julia(quipe de Recherche en pidmilogie Nutritionnelle),Dr Eszter Sarkadi-Nagy(National I
24、nsitute of Pharmacy and Nutrition,Hungary),Ms Stephanise Desnousse,Ms Judy Jean-Baptise and Ms Vereine Louis-Marie(Ministry of Health Seychelles),and colleagues from the Ministry of Health of Sri Lanka.All Member States are acknowledged for the actions taken to reduce population sodium intake.Financ
25、ial supportWHO is grateful for the financial support to develop this report from the Government of Sweden and Resolve to Save Lives.viWHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONHIC LIC high-income countries low-income countriesLMC lower-middle income countriesND not determinedUMC upper-middle-incom
26、e countriesabbreviationsviiForewordSodium reduction plays a key role in protecting populations from the burden of noncommunicable diseases,namely,cardiovascular disease which is the number one cause of death and disability globally.The evidence is clear:the more sodium we consume the more our blood
27、pressure rises,and blood pressure is reduced when dietary sodium intake is reduced.Reducing sodium intake is one of the most cost-effective ways to improve health,as it can avert millions of deaths every year at very low total programme costs.On average,we consume over 4 mg sodium every day,which is
28、 double the amount recommended by WHO.In 2013 all 194 WHO Member States committed to reducing population sodium intake by 30%by the year 2025.Since then,progress has been slow and only a few countries have been able to reduce population sodium intake,but no one has been able to achieve the target.As
29、 such,it is being considered to extend the target to 2030.We can reduce sodium intake by deciding to add less salt to the food we prepare and by deciding to buy foods that contain less sodium.Peoples behaviour change is important,and mass media campaigns to alter consumer behaviour around sodium are
30、 needed.However,several public policies need to make this choice an easier one.Food manufacturers need to reduce sodium content in food products;products with high sodium content need to be easy to identify through front-of-pack labelling;meals offered in public institutions such as schools,hospital
31、s,and public offices should contain less sodium.If the WHO recommended policies were implemented,we would see sodium consumption reduced by over 20%,getting close to the target set in 2013.The report shows which countries have adopted and implemented sodium reduction policies and is meant to encoura
32、ge bolder action from a larger number of countries.WHO will support these efforts with new and better tools,innovative approaches,advocacy initiatives and technical assistance.We can build on the success stories of the few countries who have managed to achieve a decrease of population intake of sodi
33、um.In many high-income countries,and increasingly in low-and middle-income countries,a significant proportion of sodium intake can be attributed to processed food.In 2022 WHO developed benchmarks for sodium content in 18 food categories and called on food operators to implement them globally.The ben
34、chmarks are based on real life experiences,so that their implementation is safe and technologically feasible.Some of the large food manufacturers have committed to make steps to achieve those benchmarks,but again bolder action and engagement from more actors is needed to see measurable public health
35、 impact.WHO has long been monitoring and reporting on the adoption,implementation,and impact of policies to reduce sodium.We will continue to do so and will establish a mechanism to monitor the implementation of the commitments of food operators.Implementing WHO recommended sodium intake reduction p
36、olicies may save over two million deaths by 2025 and seven million by 2030.We cannot fail this completely achievable and affordable public health goal!Dr Francesco Branca,MD,PhDDirector,Department of Nutrition for Health and Development(NHD)viiiWHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONExecutive S
37、ummaryThe global burden of unhealthy diets constitutes a major public health and development challenge worldwide.Urgent action is required to modify the production and consumption of foods and beverages,including industry manufactured(pre-packaged)food.Of greatest concern is excess consumption of so
38、dium,sugars and unhealthy fats,particularly trans-fatty acids(trans fats)and saturated fatty acids,and low consumption of whole grains,pulses,vegetables,and fruits.The largest number of diet-related deaths,an estimated 1.89 million each year,is associated with excessive intake of sodium,a well-estab
39、lished cause of raised blood pressure and increased risk of cardiovascular disease.The global average sodium intake is estimated to be 4310 mg/day(10.78 g of salt per day),which far exceeds the physiological requirement and is more than double the World Health Organization(WHO)recommendation of 2000
40、 mg of sodium(equivalent to 5 g of salt)per day in adults.Reducing sodium intake is one of the most cost-effective ways to improve health and reduce the burden of noncommunicable diseases,as it can avert a large number of cardiovascular events and deaths at very low total programme costs.WHO recomme
41、nds several sodium-related best buys policies as practical actions that should be undertaken immediately,to prevent cardiovascular disease and its associated costs.These include lowering sodium content in food products;implementing front-of-pack labelling to help consumers select food products with
42、lower sodium content;conducting mass media campaigns to alter consumer behaviour around sodium;and implementing public food procurement and service policies to reduce sodium content in food served or sold.All 194 Member States committed to reducing population sodium intake by 30%by 2025,demonstratin
43、g strong consensus on sodium reduction as a life-saving strategy.For the first time,WHO has documented progress to date on policies(through the Sodium Country Score Card)and their impact on intake and cardiovascular diseases.Furthermore,WHO proposes that if all countries accelerate policy adoption t
44、o ensure at least two mandatory interventions and implementation of best practices,it is possible to dramatically reduce intake by 2030.As of October 2022,5%of Member States(n=9)have implemented at least two mandatory sodium reduction policies and other measures,and all WHO sodium-related best buys
45、for tackling noncommunicable diseases.A further 22%of Member States(n=43)have implemented at least one mandatory policy or measure.At the same time,33%of the remaining Member States(n=64)have implemented at least one voluntary policy and other measures to reduce sodium intake,while 29%(n=56)have mad
46、e a policy commitment towards sodium reduction.Modelling indicates the estimated potential impact of policy implementation on sodium intake to be a 23%reduction,and on cardiovascular death a 3%reduction,globally,by 2030.Although the modelled global sodium reduction is below the 30%target by 2030,ach
47、ieving the target can still be considered attainable with the rapid implementation of government-led and comprehensive mandatory sodium reduction policies and other measures.WHO is committed to supporting Members States to implement,monitor and enforce policies and other measures to ensure that ever
48、y adult and child enjoys healthy food environments to realise their human right to safe,secure and nutritious food,and the highest attainable standard of health.All 194 Member States committed to reducing population sodium intake by 30%,demonstrating strong consensus on sodium reduction as a life-sa
49、ving strategyixScope and purposeThe World Health Organization(WHO)has developed this report to monitor progress and identify areas for action in the implementation of sodium reduction policies and other measures within Member States and across WHO regions and World Bank income groups.For the first t
50、ime,a Sodium Country Score from 1(the lowest level)to 4(the highest level)is allocated to each Member State based on the level of implementation of sodium reduction policies and other measures.The Sodium Country Score is used to estimate the impact of policy progress on population dietary sodium int
51、ake and cardiovascular disease.PeopleImages BACKGROUND2WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONWHO guideline:Sodium intake for adults and childrenSodium is an essential nutrient involved in the maintenance of normal cellular homeostasis,and in the regulation of fluid and electrolyte balance.It i
52、s crucial for maintaining extracellular fluid volume because of its osmotic action;and it is equally important for muscle and nerve cell function,and for the transport of nutrients through plasma membranes(6).Sodium deficiency is extremely unlikely in healthy individuals(7);the minimum intake level
53、required for physiological needs is not well established although it is estimated to be 500 mg/day sodium(8).Hence,most populations are consuming much more sodium than is physiologically necessary.Accordingly,the WHO guideline recommends:a reduction in sodium intake to reduce blood pressure and risk
54、 of cardiovascular disease,stroke and coronary heart disease in adults.WHO recommends a maximum intake of 2000 mg/day sodium(5 g/day salt)in adults;a reduction in sodium intake to control1 blood pressure in children.The recommended maximum intake of 2000 mg/day sodium(5g/day salt)in adults should be
55、 adjusted downward based on the energy requirements of children relative to those of adults.While the primary health effect associated with a diet high in sodium is raised blood pressure,there is a growing body of evidence documenting the impact of high sodium intake on a range of other health outco
56、mes,including gastric cancer(9,10),obesity(11-13),Mnires disease(14)and osteoporosis(15).Although many noncommunicable diseases(including cardiovascular diseases)are associated with older age groups,robust evidence indicates that these diseases can develop early in life,and that all age groups that
57、are affected(16).1“Control”for this recommendation refers to the prevention of a deleterious rise in blood pressure with age.An estimated 1.89 million deaths each year are associated with excessive sodium intake(1),a well-established cause of raised blood pressure and increased risk of cardiovascula
58、r disease(2-4).Reducing sodium intake is one of the most cost-effective ways to improve health and reduce the burden of noncommunicable diseases,as it can avert a large number of cardiovascular events and deaths at very low total programme costs.WHO recommends several sodium-related best buys polici
59、es and other measures as practical actions that should be undertaken immediately,to prevent cardiovascular disease and its associated costs(5).These include lowering of sodium content in food products;implementing front-of-pack labelling to help consumers select food products with lower sodium conte
60、nt;conducting mass media campaigns to alter consumer behaviour around sodium;and implementing public food procurement and service policies to reduce sodium content in food served and sold.National nutrition and/or noncommunicable disease prevention and control policies help to catalyse and integrate
61、 regulatory,legislative and multisectoral actions across health and other health relevant sectors.The development,implementation and monitoring and evaluation of sodium reduction policies should be government-led and safeguarded against possible conflicts of interest.BACKGROUND3BACKGROUNDMember Stat
62、es committed to reducing exposure to unhealthy diets.The commitment was made through a Political Declaration of the High-level Meeting of the United Nations General Assembly on the Prevention and Control of Noncommunicable Diseases(17).Member States adopted the Global Action Plan for the Prevention
63、and Control of Noncommunicable Diseases 20132020(18)to take coordinated action at all levels to attain nine voluntary global targets,including:30%relative reduction in mean population sodium intake by 2025,with a goal of 2000 mg/day sodium,25%relative reduction in the prevalence of raised blood pres
64、sure.Member States committed to the Sustainable Development Goals,including Goal 3,Good Health and Well-being of which target 3.4 stipulates by 2030:reduce by one third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being.2011201
65、32015Member State commitments to the prevention and control of noncommunicable diseases Member States adopted the Implementation Roadmap 20232030 for the Global Action Plan for the Prevention and Control of Noncommunicable Diseases,which will support countries to accelerate and implement actions to
66、improve noncommunicable disease outcomes,including sodium reduction(19).2022Member States endorsed the updated WHO best buys(5)-a set of affordable,feasible,impact-driven and highly cost-effective measures to reduce sodium intake.20175METHODS monkeybusinessimages6WHO GLOBAL REPORT ON SODIUM INTAKE R
67、EDUCTIONMETHODS This report uses several data sources and models to determine population dietary sodium intake,country-based policy implementation and corresponding score,and the policy impact on sodium intake and cardiovascular disease.Implementation of sodium reduction policies and measuresData on
68、 policy implementation were obtained from the WHO Global database on the Implementation of Nutrition Action(GINA)(20).This database includes WHO policy surveys focusing on nutrition(21),noncommunicable diseases(22)and related databases(23),a number of WHO reports at the global(24)or regional level(2
69、5-35),as well as the results of ongoing monitoring by the WHO team through its regional and country networks and systematic searches on government websites.These data cover all Member States,thus,in the report,the denominator for overall policy implementation is n=194.Additional information on Membe
70、r State policy status was sourced from relevant partner databases(36-38)and reports(39),and from recent peer-reviewed papers(40-45).For each relevant national policy or action identified,the national document was obtained through searches of government websites or legislative compilations,and analys
71、ed for potential inclusion in GINAthat is,whether it contained specific goals,strategies,or measures to reduce sodium intake.Relevant documents were added to GINA with basic reference information about the title,government agency publishing the document,date of publishing,date of going into effect,a
72、doption status,and the document and/or the link to the document on the government website.In addition,an extract of key sections was included in the documents original language and the document was catalogued in GINA using taxonomy topics for different healthy diet policies and sodium reduction meas
73、ures.Where there were doubts around relevance or status,a team discussion occurred.As needed,additional information was sought to find evidence of adoption or implementation(for example,from consulting media articles),that reformulation targets were launched(for example,from government reports or me
74、eting minutes),to check whether school food standards were initiated(for example,from school policies and government reports)and to verify that a front-of-pack labelling system is in use(for example,from online food shops in the country).This data scoping and analysis was completed for all Member St
75、ates indiscriminately.Additional searches on government websites were performed for countries with no information regarding sodium reduction policies.These data set out the overarching status of implemented sodium reduction policies and other measures.Sodium Country Score CardThe policy information
76、described above was used to develop a Sodium Country Score Card.It assesses country implementation of sodium reduction policies and other measures(both voluntary and mandatory),allocating a score from 1(the lowest level of implementation)to 4(the highest level of implementation).The Sodium Country S
77、core Card assesses policies and other measures,and assigns the highest score obtained as follows:Score 1-a national policy commitment towards sodium reduction Score 2-voluntary measures implemented to reduce sodium in the food supply or encourage consumers to make healthier food choices These measur
78、es would be considered if upper-level thresholds for sodium have been set in an underlying nutrient profile model(for example,a quantified limit for the maximum permissible amount of sodium in food served in schools),or if consumer behaviour is specifically targeted in relation to sodium(for example
79、,prohibition on saltshakers in food service areas).Score 3-mandatory measures implemented to reduce sodium and use a nutrient profile model to effectively implement measures.Declaration of sodium on all pre-packaged food is mandatory.Score 4-at least two mandatory measures to reduce sodium,mandatory
80、 sodium declaration on all pre-packaged food,and at the same time all four WHO sodium-related best buys(Figure 1).7METHODSFigure 1.Sodium Country Score Card CriteriaIt should be noted that the Sodium Country Score Card algorithm does not differentiate between key aspects of the policies and other me
81、asures,such as the number of food categories with a sodium content limit.For example,one country may have implemented voluntary reformulation targets for sodium content in processed food for a large number of food categories and is assessed as score 2,while another country implements mandatory sodiu
82、m content limit on one food category only and yet this country is potentially assessed as score 3 or 4.Similarly,the scoring algorithm does not take into account the type of front-of-pack labelling system,the number of channels or age range of children covered by the marketing restrictions,or the ty
83、pes of settings or food categories covered by the public food procurement and service policies.Finally,the data also include country reports on mass media campaigns,but information on the frequency,duration and reach of the mass media campaigns is not frequently known or evaluated.The assessment of
84、measures in the Sodium Country Score Card is based on the pathway countries may take from making a policy commitment to address a problem at(the first level),up to having at least two mandatory policies and other measures plus implementation of all best buys(the highest level),as comprehensive gover
85、nment-led mandatory policies and other measures are generally considered more effective(46)and have a history of being ineffective unless they are coupled with strong government oversight and close monitoring(47).While there are several examples of effective city-level action(48,49)to reduce sodium
86、intake,the Sodium Country Score Card mainly focuses on national programmes and therefore does not comprehensively consider stand-alone city initiatives.*WHO best buys for reducing noncommunicable diseases through reducing sodium intake8WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONPopulation dietary s
87、odium intake Estimates for mean population sodium intake were calculated by the Institute for Health Metrics and Evaluation(1).The data can be readily accessed through the WHO Noncommunicable Disease Data Portal,which provides access to detailed information on noncommunicable diseases and their risk
88、 factors(50).It should be noted that the Institute for Health Metrics and Evaluation data is not without limitations,given there is no comprehensive reporting of population sodium intake.Modelled health impact of sodium reduction policies and measuresA model was created to estimate the impact of upl
89、ifting the score of countries in the Sodium Country Score Card as a result of implementing new mandatory or voluntary policies and other measures,on mean population sodium intake,and in turn on cardiovascular disease outcomes.The baseline scenario was set to 2019,the year of the most recently availa
90、ble sodium intake estimates,and the hypothetical scenario estimated for the two end-points of 2025 and 2030(corresponding to the sodium reduction target of 30%by 2025,now extended to 2030)(Figure 2).Figure 2.Framework for estimated changes in sodium intake and cardiovascular disease based on policy
91、implementation In the baseline scenario,it was assumed that no Member State implemented any new policy or other measure and thus had no score uplift.The rate of change in sodium intake was calculated using the current average annual rate of reduction in individual Member States,based on the availabl
92、e data as of 2019,and projecting intake until 2025 or 2030.In the hypothetical scenario,each Member State was uplifted two scores or,if already at score 3 or 4 in the baseline year,achieved or sustained the highest score 4.The effect of score uplifts or sustaining a score 4 on sodium intake was calc
93、ulated using effect sizes for mandatory and voluntary policies used in a previous modelling.The effect sizes for mandatory and voluntary measures an inherent feature of the Sodium Country Score Card were considered to be in line with ongoing work by WHO to update the best buys(51),systematic reviews
94、(52)modelling studies(53,54),and documented country impact of multicomponent interventions(55,56).GlobalNoncommunicable Diseases Action PlanBaselinepointHypotheticalend-point 1Hypotheticalend-point 220030Policy and scores:Sodium intake:Health impact:Policy uplift scenarioPolicy baseline s
95、cenarioPolicy baseline scenarioPolicy uplift scenarioSodium intakereduction scenario 1Averted deaths in 2025Averted deaths in 2030Sodium intakereduction scenario 2Hypotheticalscore uplift9METHODSThe following effect sizes were used to estimate the impact of policy progress on sodium intake over an 1
96、1-year period from 2019 to 2030,where recording the estimated effect on intakes in 2025 from the 2030 projection was used as the estimated effect for that end-point.Uplift from no score to score 2=15%(based on voluntary reformulation)Uplift from score 1 to score 3=20%(based on mandatory reformulatio
97、n)Uplift from score 2 or 3 to score 4=25%(a composite value based on reformulation,procurement,and front-of-pack labelling).The corresponding health impact of reduced sodium intake on the number of deaths from cardiovascular diseases resulting from the effect of the hypothetical uplifts in score com
98、pared with the baseline projected intake was calculated for each Member State using the Noncommunicable diseases Preventive Risk Integrated ModEl(NCD prime)(57),based on the population attributable framework(58).The default parameters of NCD prime were updated to a reduction in 100 mmol/day in 24-ho
99、ur urinary sodium excretion of an associated reduction in systolic blood pressure of 5.56 mmHg as reported by Filippini et al 2021(2)and in line with the updating of Appendix 3 of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 20132030 analysis(51).It should be
100、 noted that the estimated effect size was applied to each Member State,despite known differences in the major sources of sodium in each population,therefore,it is likely that Member States with a higher discretionary sodium intake(salt added to food during cooking and/or at the table)may have a lowe
101、r estimated reduction in dietary intake,and fewer cardiovascular deaths averted in 2025 and 2030.The estimated effect sizes were also applied to Member States,regardless of existing policies and measures.RESULTS vasiliybudarin 12WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONData on population dietary
102、sodium intake,and country-based sodium reduction policies and other measures implemented are presented for all 194 WHO Member States.Also presented are the scores assessed through the Sodium Country Score Card(Annex 1),and the policies on sodium intake and cardiovascular disease.Implementation of so
103、dium reduction policies and measuresNational policy commitment National nutrition and/or noncommunicable disease prevention and control policies help to catalyse and integrate legislative and multisectoral measures across food,health and other health-relevant sectors.The development,implementation,a
104、nd monitoring and evaluation of sodium reduction policies should be government-led and safeguarded against possible conflicts of interest(59).Of the 194 Member States,79%(n=154)have a policy commitment towards sodium reduction(Figure 3).There is little variation across WHO regions,however,low-income
105、 countries less frequently have stated sodium reduction commitments.Of the Member States,56 remain in score 1 in the Sodium Country Score Card,without further measures implemented in the WHO African Region and among low-income countries,whereas 98 implement either voluntary,or mandatory policies and
106、 other measures,and are scored higher.Just under half of these Member States had already made a sodium reduction policy commitment by 2013,the year of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases and the global sodium reduction target.Box 1 describes setting
107、of national policy targets and actions in Nigeria.Figure 3.Proportion of Member States with a policy commitment to reduce sodium intake by WHO region,and World Bank income group AFR(n=47)Member States in scores 2,3 or 4Member States in score 1AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LM
108、C(n=53)UMC(n=52)HIC(n=58)46645047385627670078648583790%10%20%30%40%50%60%70%80%90%100%resultsAFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region13RESULTSBox 1.Nation
109、al policy commitment Nigeria In 2013,the National Policy and Strategic Plan of Action on Prevention and Control of Non-Communicable Diseases was established,with the objective to reduce sodium intake(60).In 2019,the National Multi-sectoral Action Plan for the Prevention and Control of Non-Communicab
110、le Diseases(2019-2025)was launched(61).This plan clearly identifies unhealthy diet as a risk factor for noncommunicable diseases,and notes that,anecdotally,food consumption patterns in Nigeria are changing rapidly towards the consumption of processed foods high in sodium.The target set for sodium re
111、duction is at least a 30%relative reduction in mean population intake of sodium.The proposed actions to achieve this target include reformulation of processed food products to contain less salt,setting maximum target levels for sodium content in processed foods and standards for front-of-pack labell
112、ing.These actions will be supported by the implementation of nutrition education and counselling,mass media and behaviour change campaigns on healthy diets,including social marketing to reduce sodium and promote the intake of fruits and vegetables.The commitments towards sodium reduction set targets
113、 for reduced population sodium intake and/or describe the approach government will take to achieve this target.These commitments are typically expressed in national nutrition plans(n=82),noncommunicable disease plans(n=94)or health sector plans(n=40).Three Member States have incorporated sodium redu
114、ction commitments into multisectoral development plans(Indonesia,Islamic Republic of Iran and Trkiye),and one Member State has incorporated sodium reduction commitments into a food sector plan(Mongolia).About a third of the Member States(37%)had sodium reduction commitments expressed in more than on
115、e policy type(Annex 2,Table A2.1).Measures to reduce sodium in the food supply or encourage consumers to make healthier food choices about sodiumWHO has identified a set of evidence-based best buy interventions to tackle noncommunicable diseases that should be undertaken immediately,with expected ac
116、celerated results in terms of lives saved,healthy life-years gained,cases of disease prevented,and costs avoided.These aim to reduce sodium intake through:reducing sodium content in a food supply(reformulation of processed/manufactured food);reducing sodium in meals or snacks consumed outside of the
117、 home(public food procurement and service policies);encouraging consumers to make healthier choices related to sodium through information(media campaigns,front-of-pack or other interpretive nutrition labelling,menu labelling or removal of saltshakers in food service areas)and absence of negative inf
118、luence(restricting marketing of food high in sodium).These policies and other measures are mutually reinforcing.As the number of policies and other measures implemented increases,there is a compound increase in immediate benefits.However,a single policy or measure can be implemented based on the res
119、ources available,and built upon with additional complementary policies and measures over time;they may also have an unintended effect.For instance,setting specific thresholds for,the maximum permissible amount of sodium in a food product in order to bear or not bear a label,may encourage reformulati
120、on of the product to reduce its sodium content.Generally,mandatory policies,whether expressed in legislation or other government guidance,are more likely to achieve impact because they have higher coverage and set a level playing field across the food manufacturing sector where all companies abide b
121、y the same limits and rules.Mandatory policies create a food environment that restricts or demotes the least healthy food options regardless of where food is served or sold.14WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONOf the 194 Member States,55%(n=119)have implemented sodium reduction policies and
122、 other measures through mandatory(5%;n=9),mandatory and voluntary(27%;n=53)or voluntary(29%;n=57)approaches(Figure 4).The most implemented sodium reduction measure is voluntary media campaigns(49%;n=96),followed by reformulation(34%;n=65)and public food procurement and service policies that are both
123、 mandatory and voluntary(Figure 4).There are significant regional discrepancies in implementation of measures and use of voluntary versus mandatory policies(Annex 3),and a consistent tendency for these measures to be more frequently implemented the higher the income group(Annex 4).Figure 4.Proportio
124、n of Member States implementing mandatory and/or voluntary sodium reduction policies and other measures Any voluntaryor mandatorymeasureReformulationMandatoryMandatory and voluntaryVoluntaryPublic foodprocurementand serviceFront-of-packlabellingMass mediacampaignsFiscal policies0%10%20%30%40%50%60%7
125、0%80%90%100%Otherinterpretativenutrition labellingMarketingrestrictions527291315RESULTSReformulation to reduce sodium content across the food supplyAn effective way to reduce population sodium intake is through lowering the sodium content of foods that are consumed f
126、requently(24,62).In many high-income countries,and increasingly in low-and middle-income countries,a significant proportion of sodium in the diet comes from processed foods such as bread,cereal and grains,processed meats,and dairy products(63).Mandatory maximum limits for sodium in processed foods p
127、romote industry-wide reformulation.It creates a marketplace that restricts the least healthy food options regardless of where people shop or how much they understand(or have access to)information on labels.This type of policy requires no consumer action and places the burden to avoid manufacturing l
128、ess healthy products on the food industry.Of the 194 Member States,34%(n=65)have implemented policies to reformulate manufactured food to contain less sodium through mandatory(11%;n=21),mandatory and voluntary(3%;n=6),or voluntary(20%;n=38)approaches(Figure 5 and Annex 2,Table A2.2).Reformulation is
129、 most commonly implemented in the WHO Eastern Mediterranean and European regions,and is more common in the higher the income group.The first reformulation policies date back to the 1980s when some Member States introduced maximum permissible limits of sodium in bread,tomato sauces or peanut butter.A
130、bout half of the Member States with mandatory or voluntary sodium reduction reformulation policies had introduced these by 2013,when the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases,which recommended reducing sodium in the food supply,was launched.Figure 5.Propor
131、tion of Member States implementing mandatory and/or voluntary reformulation policies to reduce sodium content in food by WHO region,and World Bank income group AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)0%0%10%20%30%40%50%60%70%80%90%100%0%42MandatoryM
132、andatory and voluntaryVoluntary623245669294858AFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region16WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONThe variation of sodiu
133、m content in manufactured food offers a significant opportunity for sodium reduction through reformulation and demonstrates that reducing sodium in processed food is possible,as demonstrated by the WHO global sodium benchmarks(24).It is likely that reformulation of processed foods and beverages will
134、 generate the greatest impact in reducing the consumption of sodium,particularly in countries where these foods are commonly consumed.Across the implemented reformulation policies in Member States,bread and bread products are the most targeted food category for sodium reduction,followed by processed
135、 meat,poultry,game or fish;ready-made and convenience foods and composite dishes;and savoury snacks(Figure 6).Figure 6.Number of Member States targeting different food categories through mandatory and/or voluntary reformulation policies to reduce sodium content in food2 2 The food groups are based o
136、n the 18 food categories identified in the WHO Global sodium benchmarks(24)where all but two of the food groups(edible ices;fresh and frozen fruit,vegetables and legumes)had at least one mandatory limit or voluntary target set.Three Member States(Czechia,France and Ireland)have voluntary reformulati
137、on targets that do not specify food categories and are not included in this graph.Chocolate and sugar confectionery,energy bars,and sweet toppings and dessertsCakes,sweet biscuits and pastries;other sweet bakery wares;and dry-mixes for making suchSavoury snacksBeveragesBreakfast cerealsYoghurt,sour
138、milk,cream and other similar foodsCheeseReady-made and convenience foods and composite dishesButter and other fats and oilsBread,bread products and crisp breadsFresh or dried pasta,noodles,rice and grainsFresh and frozen meat,poultry,game,fsh and similarProcessed fruit,vegetables and legumesPlant-ba
139、sed food/meat analoguesSauces,dips and dressings2462492230354045MandatoryMandatory and voluntaryVoluntary6343Processedmeat,poultry,game,fsh and similarNumber of Member States17RESULTSMandatory limits are typically set on a smaller num
140、ber of food categories,with only four Member States(Argentina,Islamic Republic of Iran,Slovakia,and South Africa)setting such limits for five or more food categories(Figure 7).Boxes 24 describe different approaches to reformulation.Figure 7.Number of Member States targeting different number of food
141、categories through mandatory and/or voluntary reformulation policies to reduce sodium content in food Box 2.Reformulation to reduce sodium content across the food supply Saudi Arabia(mandatory)In 2018,with the aim of reducing sodium content in food items,the Saudi Food and Drug Authority enforced a
142、limit of 1 g/100 g for breads(64)and salted yoghurts drinks on manufacturers.This regulation was followed by a salt guide(65)from the Saudi Food and Drug Authority inviting food manufacturers to abide by limits for sodium content for 22 processed food items.Box 3.Reformulation to reduce sodium conte
143、nt across the food supply Australia(voluntary)The Healthy Food Partnership(66)was established by the Government of Australia in 2015.The aim is to improve the dietary habits of Australians by making healthier food choices easier and more accessible,and by raising awareness of appropriate food choice
144、s and portion sizes.The programme,which defines and sets voluntary maximum sodium targets for 27 food categories was rolled out in 2020 and expanded in 2021 to include an additional three food categories(66).As an example,the target for maximum sodium content in leavened breads is 380 mg/100 g,to be
145、 met by June 2024.These targets cover 80%of the categories,by sales volume,for participating businesses.The first of six progress reports is scheduled in June 2022.Early modelling indicates that this voluntary approach is limited by the number of categories and adherence to targets,and that for sign
146、ificant sodium reduction,government-led mandatory reformulation implemented across the manufactured food supply is required(67).02468234567896236665142122MandatoryMandatory and voluntaryVoluntary24Number of Member StatesNumber of food categories18WHO GLOBAL REPORT ON
147、 SODIUM INTAKE REDUCTIONBox 4.Reformulation to reduce sodium content across the food supply South Africa(mandatory)The South African government introduced mandatory maximum limits for sodium content in 2013.The legislation was set for products in 13 food categories,including bread,breakfast cereals,
148、margarines,meat products,snack foods and soup mixes.It is estimated that approximately 60%of total sodium intake is provided from processed foods(68).Food companies were granted a period of 3 years to ensure that their products were compliant.The regulation came into effect in June 2016,and further
149、reduction was expected 3 years later in 2019(69).Evidence from the WHO Study on global AGEing and adult health suggests a reduction of 400 mg/day sodium(1.15 g/day salt)between 2015 and 2019(70,71).Although South Africa has mandatory limits on sodium in food products,it is yet to legislate mandatory
150、 sodium declarations on all pre-packaged food because the amended regulations relating to the labelling and advertising of foods amendment is under review(72).The implementation of a nutrition declaration is critical to monitoring compliance with mandatory limits on sodium content,as well as for oth
151、er food systems actions such as identifying foods low in sodium eligible for front-of-pack labelling,and for applying marketing restrictions.monkeybusinessimages19RESULTSPublic food procurement and service policiesHealthy public food procurement and service policies set nutrition criteria for food s
152、erved and sold in public settings(a limit on the use of food typically high in sodium,a maximum permissible amount of sodium in a serving of food,or a prohibition against placing saltshakers on tables)(73,74).These policies can cover the entire process of purchase,provision,distribution,preparation,
153、service and sale of food to ensure each step meets healthy criteria.Of the 194 Member States,28%(n=54)have public food procurement and service policies to reduce sodium consumption through mandatory(18%;n=36),mandatory and voluntary(3%;n=5)or voluntary(7%;n=13)approaches(Figure 8).Such policies are
154、most common in the WHO regions of the Americas,Europe and Western Pacific,and more frequently implemented in the higher the income group.These policies set a threshold for sodium in the food to be served or sold or in 15 Member States to restrict the availability of saltshakers in the service area.T
155、hese policies were from 2006 onwards,with almost a third of the Member States having introduced these measures by 2013 when the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases,which recommended reducing sodium content in foods in public service,was launched.Figure 8
156、.Proportion of Member States implementing mandatory and/or voluntary public food procurement and service policies addressing sodium by WHO region,and World Bank income group0%10%20%30%40%50%60%70%80%90%100%28453713235900AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)W
157、PR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)MandatoryMandatory and voluntaryVoluntaryAFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region20WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONGovernments worl
158、dwide have a unique opportunity and responsibility to lead by example through setting criteria for food served or sold in public settings such as government offices,schools,childcare centres,nursing homes,hospitals,health centres,community centres,seniors centres,military bases and prisons,as well a
159、s in shops or stalls surrounding these settings.Importantly,public funds should not be spent on food that is high in sodium.The most common setting in which public food procurement and service policies are applied is schools(50 of the 54 Member States)(Figure 9).Forty-three Member States set standar
160、ds for foods and beverages offered during school lunches,other meals or snacks,while 31 Member States set standards for foods and beverages sold in school cafeterias,tuckshops,snack bars or vending machines.Five Member States(Cabo Verde,Kiribati,Mongolia,Republic of Korea and Seychelles)set sodium-s
161、pecific standards for food sold around the school perimeter.Beyond the school setting,two Member States(Hungary and Saudi Arabia)have standards for all foods procured by the government,eight have standards for workplaces,government canteens or universities(Brazil,China,Malaysia,Philippines,Qatar,Sau
162、di Arabia,Singapore,Switzerland),and three(Hungary,Malaysia and Switzerland)for caring homes or hospitals.Five Member States have standards including thresholds for sodium for restaurants and food outlets(Argentina,Bolivarian Republic of Venezuela,Brunei Darussalam,Republic of Korea,Singapore)(Annex
163、 2,Table A2.3).Boxes 5 and 6 illustrate two different approaches to public food procurement.Figure 9.Number of Member States implementing mandatory and/or voluntary public food procurement and service policies addressing sodium by setting All food procured by the governmentSchoolsWorkplaces,governme
164、nt canteens or universitiesHosptials or caring homesRestaurants and food outlets234313442132MandatoryMandatory and voluntaryVoluntary2508350%10%20%30%40%50%60%70%80%90%100%21RESULTSBox 5.Public food procurement and service policies Brazil(mandatory)The Brazilian Ministry of Health published Ordinanc
165、e No.1.274 of 7 July 2016(75)to improve health in workplaces.It requires all restaurants,canteens and cafeterias within the ministry and its entities to serve and sell food that adheres to the Dietary guidelines for the Brazilian population(76).This includes using fresh or minimally processed food p
166、roducts in cooking;prohibits serving or selling sugar-sweetened beverages;and imposes strict limitations on serving,selling,promoting or advertising ultra-processed food products(as defined in the Pan American Health Organization Nutrient Profile Model,including food products with greater than or eq
167、ual to 1 mg of sodium per 1 kcal)(77).In addition to the criteria for serving and selling food in food venues,the Ordinance also applies to events and meetings held or contracted by the ministry.This includes meals and snacks served or catered during meetings,coffee breaks,celebrations and other eve
168、nts.The ministry published Guide for the preparation of healthy meals in events(78)to provide implementation guidance for meeting the criteria,while maintaining local ingredients and the cultural value of food.The guide is also intended to be applied voluntarily in other public or private institutio
169、ns.Box 6.Public food procurement and service policies Seychelles(mandatory)Seychelles adopted a National School Nutrition Policy in 2008,which sets standards for school meals,as well as guidelines for food provision in tuckshops and during fundraising and other activities.The standard for school mea
170、ls is that these should not contribute more than 30%of recommended sodium intake for school-aged children,that is,210 mg/day for children in creche,360 mg/day for children in primary school and 480 mg/day for children in secondary school.The guidelines for tuckshops and fundraising and other activit
171、ies state that no foods of low nutritional value should be offered or sold.In the 2018 revised tuckshop guidelines,foods and beverages of low,moderate and high nutritional value are being classified based on a traffic light system.The national government developed a guidance document to support impl
172、ementation of the policy,including a monitoring tool and sample lease agreement for school tuckshops.Monitoring was supposed to be done locally by school nutrition action groups in every school,comprising a teacher,student,parent,tuckshop owner,dining staff member,school nurse,dental therapist and d
173、istrict representative.However,there are very few schools where this group has been set up and still is operational.Central and local authorities also monitor nutrition in schools at least once a year using the monitoring tool,reporting results back to the management team of each corresponding schoo
174、l.Nutrition labellingNutrition labelling is a powerful tool.It not only informs consumers about the ingredients and nutrient content of the food,but can also influence consumers to make healthier choices and induce food manufactures to develop healthier food products.Nutrient declarationsDeclaration
175、 of the amount of sodium on the food label is fundamental for the implementation and monitoring of policies on reformulation,interpretive nutrition labelling such as front-of-pack-labelling,public food procurement and service policies,fiscal policies,and marketing restrictions(79).22WHO GLOBAL REPOR
176、T ON SODIUM INTAKE REDUCTIONAs required by Codex alimentarius(food code)(80),the nutrient declaration,which is usually placed on the back or side of the package and lists the nutrient content of a food,should be mandatory for all commercial pre-packaged foods.Countries are advised to adopt regulatio
177、ns following the codex guidelines on nutrition labelling(80)on how nutrient declarations should be structured and which nutrients should be mandatory to declare.The guidelines recommend stating the sodium content,but national authorities may express the total amount of sodium in salt equivalents as“
178、salt”.Of the 194 Member States,43%(n=83)have a mandatory declaration of sodium on pre-packaged food,of which 26%(n=52)have other mandatory,and 16%(n=31)have no other mandatory approaches(Figure 10).A large majority of Member States in the European Region implement mandatory nutrient declaration of s
179、odium.Figure 10.Proportion of Member States with mandatory declaration of sodium on pre-packaged food by WHO region,and World Bank income group 0%10%20%30%40%50%60%70%80%90%100%223278345412642780AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53
180、)UMC(n=52)HIC(n=58)MandatoryMandatory and voluntaryVoluntaryAFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region23RESULTSFront-of-pack labellingFront-of-pack nutrition labelling on pre-packaged foods
181、 contributes to increasing consumer awareness and enables consumers to make healthier choices,change purchasing intentions,and provide industry incentive to reformulate and produce healthier products(81,82).Of the 194 Member States,21%(n=40)have implemented front-of-pack labelling systems that inclu
182、de sodium in an underlying nutrient profile model,through mandatory(6%;n=11),mandatory and voluntary(1%;n=1)or voluntary(14%;n=28)approaches(Figure 11).Such front-of-pack labelling systems are most common in the European Region.In the European and Western Pacific regions these measures tend to be vo
183、luntary,in contrast to the Region of the Americas where they are mandatory.The first such front-of-pack labelling were voluntary endorsement logos introduced in 1998 and the early 2000s,with the first mandatory system being introduced in 2011.By 2013,about a quarter of the Member States with such me
184、asures had introduced front-of-pack labelling systems that included sodium in an underlying nutrient profile model.Figure 11.Proportion of Member States with mandatory and/or voluntary front-of-pack labelling systems,by WHO region,and World Bank income group999844740202005480%1
185、0%20%30%40%50%60%70%80%90%100%AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)MandatoryMandatory and voluntaryVoluntaryAFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western
186、 Pacific Region24WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONThe most effective systems are interpretive front-of-pack labelling systems that provide“at-a-glance”guidance on the relative healthfulness of the product,with or without additional nutrient information.Since most shoppers spend a few seco
187、nds at most examining food labels before deciding,labels must be clear and easy to understand(83).Interpretive systems therefore apply symbols,figures or cautionary text to indicate the overall healthfulness or nutrient content of a product.The most common format used in front-of-pack labelling in t
188、he context of sodium reduction was an endorsement logo(n=15).Such logos and summary indicators were always implemented voluntarily.Warning signs were the most common mandatory scheme,implemented especially in Latin America and in Israel.The multiple traffic light and proportion of daily intake syste
189、ms were implemented through both mandatory and voluntary approaches(Figure 12;Annex 2,Table A2.4).Member States typically implement one single front-of-pack labelling system,except two Member States(Indonesia,Thailand)that have two systems.Figure 12.Number of Member States with mandatory or voluntar
190、y front-of-pack labelling systems0246810121416MandatoryVoluntary15451287Endorsement logoMultiple trafc light systemProportion of daily intakeSummary indicatorWarning sign15938725RESULTSBoxes 710 describe different approaches to front-of-pack labelling systems in Chile,Sri Lanka,Australia and New Zea
191、land,and France,respectively.Box 7.Front-of-pack labelling systems Chile(mandatory)The Food Composition and Food Advertising Law(2013)(84),enforced by the decree Modifica decreto supremo n 977,de 1996,reglamento sanitario de los alimentos(2015)(85),requires front-of-package warning labels(“high in”)
192、on packaged foods that exceed specific thresholds for sodium(10 mg/100 g in food or food products).It is the first law to simultaneously regulate a front-of-pack warning label,place restrictions on food marketing to children under 14 years of age,and set restrictions on the school food environment.T
193、he objectives are to protect children and promote informed selection of food,and decrease consumption of food with excessive amounts of sugars,sodium and saturated fat.The warning label was developed based on quantitative and qualitative studies conducted with different population groups.The warning
194、 label performed the best in terms of visibility,understanding and intention to purchase.Chile chose to use cut-off values per 100 g instead of per serving because research found that the Chilean population was not aware of the definition of serving size,and therefore using this reference would make
195、 the label more difficult to interpret.Using a per 100 g reference allows for a standard measure for all foods,as it describes food based on the nutritional quality of the food,not the way it is consumed,and allows comparison both within and between categories.Evaluation after implementation of the“
196、high in”warning label showed strong public support,and impact on both purchasing behaviour and product reformulation(85).Chile has an enforcement system in place with sanctions for noncompliance.Box 8.Front-of-pack labelling systems Sri Lanka(mandatory)Food(Colour Coding for Sugar,Salt and Fat)Regul
197、ations 2019-No 2119/3(86)legislates mandatory front-of-pack labelling regulations for pre-packaged solid and semi-solid processed foods based on the content of sugar,salt and fats.The amount of salt specified is as follows:Total Salt content in Solid or Semi-solid FoodRed logo:salt content(per 100 g
198、):More than 1.25 g Amber logo:salt content(per 100 g):0.25 g to 1.25 g Green logo:salt content(per 100 g):Less than 0.25 g This legislation was introduced in April 2019 and was to come into force from 1 June 2019.However,it has been operating since 1 January 2021 due to several industrial concerns.S
199、everal factors have influenced the development and approval of the legislation,including;the increasing burden of noncommunicable diseases in Sri Lanka,the positive international momentum for evidence-based interventions,a dedicated Food Control Administration unit within the Ministry of Health to c
200、oordinate and implement legislation,and the Food Advisory Committee a multiple stakeholder committee to advise the Minister of Health on formulation of regulations under the provisions of the Food Act in Sri Lanka.26WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONBox 9.Front-of-pack labelling systems Au
201、stralia and New Zealand(voluntary)Australia and New Zealand have implemented a voluntary front-of-pack nutrition label the Health Star Rating system.The Health Star Rating system summarizes the nutritional quality of a product and assigns it a rating from 0.5 stars(least healthy)to 5.0 stars(most he
202、althy)in 10 half-star increments(87,88).The rating is calculated based on an algorithm generating points.The lower the number of points,the better Health Star Rating score,based on a range of points for each food and beverage category.For sodium,the points range from 0 for food products with a sodiu
203、m content of 90 mg/100 g or 100 ml and up to 30 for those with a sodium content of 2700 mg/100 g or 100 ml.In 2019,at the 5 year review,the Health Star Rating system appeared on 31%of eligible products in Australia,and 21%in New Zealand(89).Research in both countries indicates that the system is dri
204、ving healthier reformulation of some products(90)for example,the sodium content of products in New Zealand decreased by almost 5%(91).Nonetheless,research indicates that the slow uptake by only a small proportion of companies illustrates the limits of commercial goodwill in applying front-of-pack la
205、belling systems voluntarily(92).The 5 year review concluded that if uptake did not reach 70%within a further 5 years,the Health Star Rating system should be mandated to provide consumers with the full benefit.Box 10.Front-of-pack labelling systems France(voluntary)Nutri-Score(France)is underpinned b
206、y a nutrient profiling system derived from the United Kingdoms Food Standards Agency nutrient profiling model(93,94).Nutri-Scores nutrient profiling system allocates points for“unfavourable”content:energy(kJ;010 points),total sugar(g;010 points),saturated fatty acids(g;010 points)and sodium(mg;010 p
207、oints),and subtracts points for“favourable”content:fruit,vegetable and nuts(05 points),fibre(05 points)and protein(05 points).Foods with a sodium content of less or equal to 90 mg/100 g scores zero points,and foods with a sodium content of more than 900 mg/100 g scores the maximum of 10 points.The r
208、esulting final score ranges between 15 and+40(most healthy foods to less healthy foods).Therefore,the lower the score the healthier the food.Nutri-Score defines five categories of nutritional quality ranging from“green”to“red”,and letters A to E.The entire scale appears on the label.Companies must a
209、dhere to certain requirements,such as size and colour.Industry is not permitted to modify,add or remove any elements of the Nutri-Score logo(95).Multiple studies have assessed perception,understanding and use of the Nutri-Score label in purchasing situations,and demonstrated a positive impact,includ
210、ing sub-analyses in disadvantaged populations(96).Other interpretive nutrition labelling approaches Menu labelling in food service facilities enables healthier consumer choices in restaurants and canteens,or labelling of food options in vending machines.These schemes can be voluntary or mandatory fo
211、r specific settings or outlets,and indicate the nutrients to be displayed.Other interpretive labelling includes back-of-pack warning messages on,for example,high sodium content and the associated health risks.Argentina(97),Finland(98-101)and Indonesia(102)have implemented mandatory warning messages
212、on foods high in sodium;these can be placed anywhere on the package and are therefore not considered front-of-pack labelling.Finland implemented a mandatory salt warning in 1991.China(103-106)and Malaysia(107)have implemented voluntary menu labelling,including sodium among other nutrients for purcha
213、se point labelling on,for example,boards,tables and electronic menus,as well as packaging and liners of food products,trays,tableware or takeaway wrapping in settings such as government canteens,schools,restaurants and restaurant/fast food chains.Malaysia implemented the measure in 2008.27RESULTSMas
214、s media campaignsMass media play an important role in information delivery to much of the population.Sodium reduction campaigns may be targeted to influence a specific behaviour,change social norms or educate consumers and/or other stakeholders,or to support the development or implementation of sodi
215、um reduction policies.Education and communication work best as part of a comprehensive package of actions rather than in isolation.Of the 194 Member States,49%(n=96)have had a government-led mass media campaign focusing on sodium reduction,which were reported to WHO in 20162017 or later(Figure 13).M
216、ost frequently implemented in the European Region and among high-income countries,such campaigns are also implemented by many countries in the remaining regions and income groups.Figure 13.Proportion of Member States with mass media campaigns by WHO region,and World Bank income group 0%10%20%30%40%5
217、0%60%70%80%90%100%918405867AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)AFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region28WHO GLOBAL REPOR
218、T ON SODIUM INTAKE REDUCTIONBoxes 1113 describe three approaches to mass media campaigns in China,Kazakhstan and South Africa,respectively.Box 11.Mass media campaigns China In China,WHO and Resolve to Save Lives worked with the National Institute for Nutrition and Health(Chinese Center for Disease C
219、ontrol and Prevention)and Tsinghua University,using the evidence-based communication for health(108)approach to design,test and measure the impact of behavioural insights interventions to reduce sodium intake.Data collected in 2019(109)suggested that despite public awareness that high sodium consump
220、tion is unhealthy,many people still found it difficult reduce salt when eating out because of lack of options and because they were reluctant to ask for a dish to be modified.To address these barriers,a research study tested the effectiveness of communication and behavioural interventions on consume
221、r interaction with a popular online food delivery platform in multiple Chinese cities by delivering health messages and making changes to the choice architecture on the app.Findings from the study showed that a health message alone,compared with the control group,was not effective in nudging consume
222、rs towards lower-salt dishes.In contrast,changes to the choice architecture,in which consumers were presented with a submenu with options for“regular salt”and“reduced salt”,were effective in prompting these consumers to choose healthier options compared to the control group.Additional laboratory stu
223、dies to verify compliance by restaurants found that menu items ordered as“low sodium”options had on average 25%less sodium than dishes ordered with standard sodium settings.The study holds promise for future research interventions,and WHO and its partners plan to use these results to further explore
224、 health promotion strategies in China and inform policy recommendations,where applicable.Box 12.Mass media campaigns Kazakhstan The burden of noncommunicable disease poses significant challenges for the health system in Kazakhstan,where the COVID-19 pandemic has exacerbated access to services and ca
225、re.To prevent noncommunicable diseases,the government is developing and strengthening policies to improve the food environment,including sodium reduction strategies.Like many countries,several challenges to reducing sodium intake have been noted,including but not limited to,resistance from the indus
226、try and business sectors,and population behaviours,cultural norms and traditions.While preparations for reducing the sodium content of manufactured foods and drinking water are underway,the development of a communication campaign is a key priority.The campaign will target the general population,but
227、with a focus on women,with a series of key messages on how to reduce sodium in the home.Box 13.Mass media campaigns South Africa An advocacy group,Salt Watch,was formed in 2014 and funded,in part,by the National Department of Health through the Heart and Stroke Foundation South Africa.It was mandate
228、d to run a mass media campaign to increase public awareness related to the association between high sodium intake,blood pressure and cardiovascular disease,as well as identifying foods high in sodium and the need to reduce sodium added during cooking and to food at the table.The campaign was based o
229、n behaviour change principles and featured a well-known South African medical doctor and media personality.After extensive piloting,the campaign ran for 6 months,with an average of 44 television airings and 131 radio airings per month.The campaign was supported by activities including information an
230、d education materials,the Salt Watch website,and tools such as lower-sodium recipes that were distributed across various settings and to health care professionals.The campaign further generated additional print and social media exposure and pick-up.An evaluation of the campaign reported a significan
231、t behaviour change towards taking steps to control sodium intake.29RESULTSMarketing restrictions Marketing impacts food preferences,purchase requests and consumption patterns(110-112).Implementing marketing restrictions limits exposure to these foods and beverages,decreases demand,and provides indus
232、try incentive to reformulate and market healthier products(111).In 2010,the World Health Assembly adopted a set of recommendations on the marketing of foods and non-alcoholic beverages to children,which calls for national and international action to reduce the impact on children of marketing of food
233、s high in saturated fats,trans-fatty acids,free sugars,or salt(113).In 2020,the WHO-UNICEF Lancet Commission on Child Health noted that commercial marketing of products that are harmful to children(unhealthy foods,tobacco,alcohol,formula milk,sugar-sweetened beverages,potentially damaging social med
234、ia,and the inappropriate use of personal data)is one of the most underappreciated risks to health and well-being(114).Of the 194 Member States,13%(n=25)have implemented policies to restrict the marketing of food and non-alcoholic beverages that include sodium in an underlying nutrient profile model
235、to identify which food products are not allowed to be marketed through mandatory(9%;n=18),mandatory and voluntary(1%;n=1)or voluntary(3%;n=6)approaches(Figure 14).Such marketing restriction policies were most frequent in the Region of the Americas,where they also were mandatory,and among higher-inco
236、me groups of countries.These policies were implemented from 2008 onwards.By 2010,which was the year WHO adopted a set of recommendations on marketing of food and non-alcoholic beverages to children,16%of these Member States had introduced such measures,and 32%had introduced them by 2013,when the WHO
237、 Global Action Plan for the Prevention and Control of Noncommunicable Diseases was launched.Figure 14.Proportion of Member States with mandatory and/or voluntary marketing restriction measures that includes sodium in an underlying nutrient profiling model by WHO region,and World Bank income group 0%
238、10%20%30%40%50%60%70%80%90%100%MandatoryMandatory and voluntaryVoluntary3011061228AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)AFR:African Region;AMR:Region of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:S
239、outh-East Asia Region;WPR:Western Pacific Region30WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONThese measures most frequently restrict marketing in and around schools or settings where children gather(n=18)and typically with mandatory approaches,followed by restriction of marketing on television and
240、radio(n=13)(Figure 15,Annex 2,Table A2.5).Only six Member States have marketing restrictions on Internet,or in social media,apps or emails,and and only two Member States(Brunei Darussalam and Chile)restrict marketing across all media platforms.Two Member States(Cabo Verde and Panama)have mandatory p
241、olicies that only apply to schools,and two Member States(Brazil and Peru)have policies that only require a mandatory health warning or message on advertisements.Figure 15.Number of Member States with mandatory and/or voluntary marketing restriction measures that includes sodium in an underlying nutr
242、ient profiling model addressing different channels and settings02468031434Any advertisement in any mediaTV and radioInternet,social media,apps,emailsStreets,stores,cinemasIn and around schools or settings where children gatherSponsorshipMandatoryMandatory and voluntaryVoluntary
243、2136718731RESULTSBoxes 14 and 15 describe two mandatory approaches to marketing restrictions in Chile and the Republic of Korea,respectively.Box 14.Marketing restrictions Chile(mandatory)The Food Composition and Food Advertising Law(2013)(84),enforced by the decree Modifica decreto supremo n 977,de
244、1996,regalement sanitario de los alimentos(2015)(85),requires front-of-package warning labels on packaged foods that exceed specific thresholds for sodium(10 mg/100g in food or food products).The law then uses the warning labels as the basis for additional,coordinated regulations that prohibit produ
245、cts that carry warning labels from being sold at school kiosks or marketed to children,including on school property.The marketing restrictions also prohibit the use of child-directed marketing tactics,such as using cartoon characters or other animations,on packages or advertisements.The regulation a
246、lso requires nutrition education for all kindergarten,primary and secondary students.Early results indicate that after the initial implementation of the regulations,there was a significant decrease in the amount of sodium in packaged foods(savoury spreads,cheeses,ready-to-eat meals,sausages,and soup
247、s)(117).To support the implementation of the regulations and raise awareness about the warning label,an advertising campaign consisting of commercials,videos and downloadable posters was conducted(118).Box 15.Marketing restrictions Republic of Korea(mandatory)The Special Act on Safety Management of
248、Childrens Dietary Lifestyle(2008)(115)restricts television advertising of energy-dense,nutrient-poor food and beverages during childrens prime time viewing(from 17:00 to 19:00).The nutrient standards for high-calorie and low-nutrient food includes a threshold for sodium content of maximum 600 mg/ser
249、ving.It also bans child-directed marketing tactics,such as free give-away toys or gifts with the purchase of nutritionally inadequate foods.The regulation has resulted in changes in television advertising practices of food companies.In comparing television advertisements of energy-dense,nutrient-poo
250、r foods aired on the five major channels before and after the regulations implementation,the total advertising budget,number of advertisement placements,and rating points decreased significantly during both regulated and nonregulated hours.The total advertising budget decreased by 31%,and the number
251、 of advertisement placements dropped by 58%(from 6528 placements in 2009 to 2731 placements in 2010)(116).Fiscal policies Fiscal policies may include taxes on unhealthy foods and beverages or the removal of industry tax benefits for development and marketing of foods high in sodium.The public health
252、,economic and social benefits include the generation of tax revenue;industry incentive to reformulate and market healthier products;and reducing consumption and the associated harms.Taxes are typically financially regressive for lower-income individuals but are considered progressive because of bene
253、fits to nutrition and health.The benefits of the health effect are increased if the tax revenues are used for other health promotion strategies,including retail,manufacturing or agricultural incentives to reduce the price of healthier food products.Rather than being punitive,economic incentives and
254、disincentives“normalize”the market by bringing the prices of different foods closer to their true societal cost (119).Of the 194 Member States,one Member State(Hungary)has had an excise tax since 2011 targeting foods high in sodium through underlying nutrient profile modelling.Several other Member S
255、tates tax foods that may be typically high in sodium,such as salty snacks or bouillon cubes,but are without a threshold for sodium content in an underlying nutrient profile model and therefore not included in the Sodium Country Score Card.32WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONBox 16 describe
256、s the Hungarian approach to fiscal policies targeting foods high in sodium.Box 16.Fiscal policies Hungary(mandatory)In Hungary,the Public Health Product Tax came into effect in September 2011.It is intended to reduce consumption of foods containing unhealthy levels of sugar,salt and other ingredient
257、s,promote healthy eating and create an additional mechanism for financing public health services(120).This specific excise tax is applicable to pre-packed and non-staple foods only,paid on a per unit measure(kg,litre)and based on sugar,salt and methylxanthine(caffeine)content,with rates varying depe
258、nding on the product category.From 2022 the nutrient profile model was complemented with saturated fatty acids for salty snacks,and fibre content for the newly added food category mueslis and breakfast cereals.The tax applies to soft drinks,energy drinks,flavoured beers,alcoholic soda beverages,pre-
259、packaged sweetened products,bakery products,cocoa-containing products,fruit preserves,salty snacks,bouillons,condiments,mueslis and breakfast cereals,and filled pastry and pasta products.From July 2022,products where added sugar was substituted with artificial sweeteners are also subject to the tax.
260、The first impact assessment,in 2012 showed that after initiating the tax,consumption of taxed food products decreased concomitantly with the decrease in the supply and sale of those products.The 2018 impact assessment revealed that this effect could not be sustained,and the ratio of adults consuming
261、 products subject to the tax increased in 2018 compared with 2012.The tax did,however,reach its purpose in terms of generating revenue for public health programmes and realizing the estimated tax revenue.A positive consequence of the Public Health Product Tax is that approximately 40%of unhealthy fo
262、od product manufacturers changed their product formulas to either reduce or eliminate unhealthy ingredients(28%and 12%,respectively).Although this behaviour does not generate revenue for the budget,it reduces the availability of unhealthy food items and may result in lower health system costs for di
263、et-related chronic diseases(121).An important lesson from the experience in Hungary is that the use of a nutrient profile model to differentiate tax rates,and making sure that there are healthy food substitutes,makes the development of such taxes easier.It is also necessary to regularly review the r
264、ange of included products and tax rates.33RESULTSSodium Country Score CardThe Sodium Country Score Card monitors a countrys progress in making national commitments and taking a multifaceted approach to implementing policies to reduce sodium intake(20).As of October 2022,5%of Member States(n=9)have i
265、mplemented at least two mandatory sodium reduction policies and all WHO sodium-related best buys for tackling non communicable diseases.A further 22%of Member States(n=43)have implemented at least one mandatory policy.This means that 26%of the worlds population live in countries with mandatory measu
266、res towards sodium reduction,including mandatory declaration of sodium.At the same time,33%of Member States(n=64)have implemented at least one voluntary policy to reduce sodium intake,while 29%of Member States(n=56)have made a policy commitment towards sodium reduction.The higher the income group,th
267、e higher the score reached.In terms of regional differences,the European Region has the highest level of scores 3 and 4(Map 1,Figure 16).Map 1.Global sodium reduction policies and measures as of October 20221.National policy commitment to reduce sodium intake:National policies,strategies or action p
268、lans that express a commitment to reduce sodium intake2.Voluntary measures to reduce sodium:Voluntary measures that reduce sodium in the food supply or encourage consumers to make healthier food choices about sodium3.Mandatory measures adopted for sodium reduction:Mandatory measures to reduce sodium
269、 in the food supply or encourage consumers to make healthier food choices,including mandatory declaration of sodium on all pre-packged food 4.Multiple mandatory measures adopted for sodium reduction,and implementation of all related WHO Best Buys for tackling NCDs:Multiple mandatory measures,mandato
270、ry declaration of sodiu mon all pre-packged food,and all WHO sodium-related best buys Mandatory measures for sodium reduction adopted to bring country to Score 3(not yet all in efect Missing data34WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONFigure 16.Sodium Country Scores by WHO region,and World Ban
271、k income group 0%10%20%30%40%50%60%70%80%90%100%Global(n=194)Score 1Score 2Score 3Score 4Missing data or no score27595439226456AFR(n=47)AMR(n=35)EMR(n=21)EUR(n=53)SEAR(n=11)WPR(n=27)LIC(n=28)LMC(n=53)UMC(n=52)HIC(n=58)AFR:African Region;AMR:Regi
272、on of the Americas;EMR:Eastern Mediterranean Region;EUR:European Region;SEAR:South-East Asia Region;WPR:Western Pacific Region35RESULTSSodium Country Score Cards:African RegionIn the African Region(Table 1),no Member State has reached score 4.However,Seychelles is the first Member State to reach sco
273、re 3,as the result of the implementation of a public food procurement and service policy(Box 6,page 21)that mandates standards for sodium content and having implemented mandatory declaration of sodium on pre-packaged food.In addition,four other Member States have implemented mandatory measures but d
274、o not fully qualify for score 3:Cabo Verde,Mauritius and South Africa have mandatory measures with an underlying nutrient profile model that includes sodium,but do not have a mandatory sodium declaration on all pre-packaged food.The mandatory limits on salt in food products in South Africa is descri
275、bed in Box 4(page 18).On the other hand,Algeria has mandatory declaration of sodium on pre-packaged food but no other mandatory measure.Ten Member States only have voluntary policies to reduce sodium and remain in score 2;these are media campaigns(Algeria,Cabo Verde,Comoros,Eritrea,Gambia,Guinea,Mad
276、agascar,Mauritania,South Africa)but also voluntary reformulation targets(Senegal).Box 13(page 29)describes voluntary mass media campaigns in South Africa.Finally,26 Member States in the Region(55%)only have a national policy commitment to reduce sodium intake with no further voluntary or mandatory m
277、easures and therefore remain in score 1.This makes the African Region the region with the highest share of Member States that only have a national policy commitment.For the remaining 10 Member States(Angola,Botswana,Cameroon,Congo,Democratic Republic of the Congo,Equatorial Guinea,Guinea-Bissau,Libe
278、ria,Malawi,South Sudan),there has either been no action to reduce sodium intake or the status is unknown(Annex 1).Table 1.Sodium reduction policies and other measures implemented in the African RegionScore 2At least one voluntary policyAlgeria,Cabo Verde,Comoros,Eritrea,Gambia,Guinea,Madagascar,Maur
279、itania,Senegal,South Africa10Score 1A national policy commitment Benin,Burkina Faso,Burundi,Central African Republic,Chad,Cte dIvoire,Eswatini,Ethiopia,Gabon,Ghana,Kenya,Lesotho,Mali,Mauritius,Mozambique,Namibia,Niger,Nigeria,Rwanda,Sao Tome and Principe,Sierra Leone,Togo,Uganda,United Republic of T
280、anzania,Zambia,Zimbabwe26Score 3At least one mandatory policy+a declaration of sodium on pre-packaged foodSeychelles1At least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 4036WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONSodium Country S
281、core Cards:Region of the AmericasIn the Region of the Americas(Table 2),Brazil,Chile,Mexico and Uruguay have reached score 4,and implement at least two mandatory policies for sodium reduction,and all WHO sodium-related best buys for tackling noncommunicable diseases.All four countries have mandatory
282、 public food procurement and service and front-of-pack labelling,but voluntary reformulation of food.Chile,Brazil and Uruguay also have mandatory marketing restrictions.The mandatory public food procurement and service policy in Brazil(Box 5,page 21),and the mandatory front-of-pack labelling system
283、and marketing restrictions in Chile(Boxes 7 and 15,pages 25 and 31).In addition,Argentina has adopted mandatory front-of-pack labelling and marketing restrictions that will come into effect in December 2022,this will result in an uplift to score 4.Another four Member States(Costa Rica,Ecuador,El Sal
284、vador,Peru)have at least two mandatory measures,but they do not implement all the best buys which would result in an uplift to score 4.In particular,reformulation is only implemented by Costa Rica;front-of-pack labelling by Ecuador and Peru;public food procurement and service policies by Costa Rica,
285、El Salvador and Peru;and media campaigns by Costa Rica and Ecuador.Mandatory policies for sodium reduction are in effect for an additional seven Member States that are in score 3 in particular,public food procurement and service policies(Argentina,Costa Rica,El Salvador,Peru,United States of America
286、),marketing restrictions(Costa Rica,Ecuador,El Salvador,Peru),but less so front-of-pack labelling(Ecuador,Peru)or mandatory limits on sodium content in food(Argentina,Paraguay).In addition,Colombia has adopted front-of-pack labelling that will come into effect in December 2022,and the Plurinational
287、State of Bolivia has adopted a law covering mandatory declaration of sodium,front-of-pack labelling,other mandatory labelling(menu labelling or warning messages)to indicate sodium content and marketing restrictions,which will come into effect when regulations are finalised.These will result in an up
288、lift to score 3 for both countries.Panama and the Bolivarian Republic of Venezuela both have mandatory public food procurement and service with an underlying nutrient profile model that includes sodium,while the Bolivarian Republic of Venezuela also has mandatory front-of-pack labelling.Neither coun
289、try has mandatory sodium declaration on all pre-packaged food,whereas Canada,Guatemala,Honduras and Nicaragua have mandatory declaration of sodium on pre-packaged food but no other mandatory measure.A sodium declaration on all pre-packaged food plus a mandatory policy would have uplifted the score o
290、f these countries to 3.Eleven Member States only have voluntary policies to reduce sodium and are in score 2 in particular,media campaigns(Antigua and Barbuda,Bolivarian Republic of Venezuela,Canada,Cuba,Guatemala,Jamaica,Saint Vincent and the Grenadines,Suriname)but also public food procurement and
291、 service(Barbados,Haiti),and reformulation(Canada,Colombia).Another eleven Member States remain in score 1,only having a national policy commitment to reduce sodium intake(Annex 1).No information was available for Dominica.Table 2.Sodium reduction policies and other measures implemented in the Regio
292、n of the AmericasAt least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 4Brazil,Chile,Mexico,Uruguay4Score 3At least one mandatory policy+a declaration of sodium on pre-packaged foodArgentina,Costa Rica,Ecuador,El Salvador,Paraguay,Peru
293、,United States of America7Score 2At least one voluntary policyAntigua and Barbuda,Barbados,Canada,Colombia,Cuba,Guatemala,Haiti,Jamaica,Saint Vincent and the Grenadines,Suriname,Venezuela(Bolivarian Republic of)11Score 1A national policy commitment Bahamas,Belize,Dominican Republic,Grenada,Guyana,Ho
294、nduras,Nicaragua,Panama,Saint Kitts and Nevis,Saint Lucia,Trinidad and Tobago1137RESULTSSodium Country Score Cards:Eastern Mediterranean RegionIn the Eastern Mediterranean Region(Table 3),Saudi Arabia is the first Member State to reach score 4 and implement at least two mandatory policies for sodium
295、 reduction,namely reformulation(Box 2,page 17)and public food procurement and service policies,and all WHO sodium-related best buys for tackling noncommunicable diseases.In addition,Bahrain and the Islamic Republic of Iran have at least two mandatory measures,but do not implement all the best buys t
296、hat would result in an uplift to score 4.Both implement reformulation,but Bahrain does not implement front-of-pack labelling and the Islamic Republic of Iran does not implement public food procurement and service policies;neither country has reported media campaigns.Mandatory policies for sodium red
297、uction are in effect for an additional three Member States,notably mandatory limits of sodium in food(Bahrain,the Islamic Republic of Iran),public food procurement and service policies(Bahrain,Qatar)and front-of-pack labelling(the Islamic Republic of Iran),achieving score 3.In addition,Iraq has mand
298、atory limits on sodium in food products,Jordan has mandatory limits on sodium in food products and mandatory public food procurement and service with an underlying nutrient profile model that includes sodium,and Oman has mandatory limits on sodium in food products.None of these three countries have
299、a mandatory declaration of sodium on all pre-packaged food,which would have resulted in an uplift to score 3.On the other hand,Kuwait and United Arab Emirates have mandatory declaration of sodium on pre-packaged food but no other mandatory measure that would result in an uplift to score 3.The larges
300、t proportion of Eastern Mediterranean Region Member States(38%)are in score 2,with eight Member States only having voluntary policies to reduce sodium,including voluntary reformulation targets(Egypt,Kuwait,Tunisia),media campaigns(Iraq,Lebanon,Morocco)and front-of-pack labelling(United Arab Emirates
301、).Three Member States only have a national policy commitment to reduce sodium intake and are in score 1(Annex 1).No information was available for six Member States;Libya,Pakistan,Somalia,Sudan,Syrian Arab Republic and Yemen.Table 3.Sodium reduction policies and other measures implemented in the East
302、ern Mediterranean RegionScore 2At least one voluntary policyEgypt,Iraq,Kuwait,Lebanon,Morocco,Oman,Tunisia,United Arab EmiratesAt least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 4Saudi Arabia1Score 3At least one mandatory policy+a d
303、eclaration of sodium on pre-packaged foodBahrain,Islamic Republic of Iran,Qatar38Score 1A national policy commitment Afghanistan,Djibouti,Jordan338WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONSodium Country Score Cards:European RegionIn the European Region(Table 4)Czechia,Lithuania and Spain are the
304、first three Member States to reach score 4.They have at least two mandatory measures implemented for sodium reduction,including mandatory declaration of sodium content on all pre-packaged food,and implementation of all WHO sodium-related best buys for tackling noncommunicable diseases.All three Memb
305、er States implement mandatory public food procurement and service policies and marketing restrictions;Spain additionally has mandatory limits on sodium in food.In addition,Bulgaria,Greece,Hungary,Ireland,Israel,Latvia,Malta,Portugal and Trkiye have at least two mandatory measures,but do not implemen
306、t all the best buys,which would results in an uplift to score 4-in particular,front-of-pack labelling(only implemented in Israel,which is the only Member State without reformulation policies)and media campaigns(not implemented by Hungary,Israel,Portugal and Republic of Trkiye),The largest proportion
307、 of European Region Member States(47%)are in score 3,with mandatory policies for sodium reduction are in effect in 25 Member States in particular,mandatory limits on sodium in food(Austria,Belarus,Belgium,Bulgaria,Croatia,Greece,Hungary,Latvia,Montenegro,Netherlands,Portugal,Serbia,Slovakia,Uzbekist
308、an)and public food procurement and service policies(Bulgaria,Estonia,France,Greece,Hungary,Ireland,Israel,Latvia,Malta,Poland,Romania,Trkiye,Ukraine,United Kingdom).European Member States also implemented mandatory marketing restrictions(Ireland,Malta,Portugal,Trkiye),front-of-pack labelling(Israel)
309、and other interpretive labelling(Finland),as well as taxation on food high in sodium(Hungary,Box 16 page 32).Furthermore,another 16 Member States(Albania,Bosnia and Herzegovina,Cyprus,San Marino,Denmark,Georgia,Germany,Iceland,Italy,Luxembourg,North Macedonia,Norway,Republic of Moldova,Slovenia,Swed
310、en and Switzerland)have mandatory declaration of sodium on pre-packaged food but no other mandatory measure that would result in an uplift to score 3.Seventeen Member States only have voluntary policies to reduce sodium and remain in score 2 in particular,front-of-pack labelling(Denmark,Germany,Icel
311、and,Italy,Luxembourg,Norway,Russian Federation,Slovenia,Sweden,Switzerland),voluntary reformulation targets(Azerbaijan,Denmark,Germany,Italy,Norway,Slovenia,Sweden,Switzerland)and media campaigns(Bosnia and Herzegovina,Denmark,Georgia,Iceland,Kazakhstan,North Macedonia,Norway,Republic of Moldova,Tur
312、kmenistan),but also public food procurement and service policies(Iceland,Republic of Moldova,Sweden,Switzerland)and marketing restrictions(Denmark,Iceland,Slovenia).Boxes 10(page 26)and 12(page 28)describe a voluntary front-of-pack labelling system in France and a media campaign in Kazakhstan,respec
313、tively.Six Member States have only a national policy commitment to reduce sodium intake and therefore remain in score 1,whereas in the remaining two Member States(Andorra and Monaco)there has either been no action to reduce sodium intake or the status is unknown(Annex 1).Table 4.Sodium reduction pol
314、icies and other measures implemented in the European RegionAt least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 4Czechia,Lithuania,Spain3Score 3At least one mandatory policy+a declaration of sodium on pre-packaged foodAustria,Belarus,
315、Belgium,Bulgaria,Croatia,Estonia,Finland,France,Greece,Hungary,Ireland,Israel,Latvia,Malta,Montenegro,Netherlands,Poland,Portugal,Romania,Serbia,Slovakia,Trkiye,Ukraine,United Kingdom,Uzbekistan25Score 2At least one voluntary policyAzerbaijan,Bosnia and Herzegovina,Denmark,Georgia,Germany,Iceland,It
316、aly,Kazakhstan,Luxembourg,North Macedonia,Norway,Republic of Moldova,Russian Federation,Slovenia,Sweden,Switzerland,Turkmenistan17Score 1A national policy commitment Albania,Armenia,Cyprus,Kyrgyzstan,San Marino,Tajikistan639RESULTSSodium Country Score Cards:South-East Asia RegionIn the South-East As
317、ia Region(Table 5),no Member State has reached score 4.Indonesia,Sri Lanka,and Thailand have implemented mandatory policies for sodium reduction as well as mandatory declaration of sodium on pre-packaged food,and so have reached score 3.Sri Lanka and Thailand have mandatory front-of-pack labelling w
318、hereas Indonesia has other interpretive labelling.In addition,Bangladesh and India have mandatory declaration of sodium on pre-packaged food but no other mandatory measure and so remain in score 2.The other Member States in score 2 have only voluntary policies to reduce sodium,including media campai
319、gns(Bhutan,Democratic Peoples Republic of Korea,India,Timor-Leste)and voluntary reformulation(Bangladesh).Three Member States are in score 1,having only a national policy commitment to reduce sodium intake(Annex 1).Table 5.Sodium reduction policies and other measures implemented in the South-East As
320、ian RegionAt least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 40Score 3At least one mandatory policy+a declaration of sodium on pre-packaged foodIndonesia,Sri Lanka,Thailand3Score 2At least one voluntary policyBangladesh,Bhutan,Democ
321、ratic Peoples Republic of Korea,India,Timor-Leste5Score 1A national policy commitment Maldives,Myanmar,Nepal340WHO GLOBAL REPORT ON SODIUM INTAKE REDUCTIONSodium Country Score Cards:Western Pacific RegionIn the Western Pacific Region(Table 6),Malaysia is the first Member State to reach score 4.It ha
322、s at least two mandatory measures implemented for sodium reduction,notably limits on sodium in food and public food procurement and service policies,as well as mandatory declaration of sodium content on all pre-packaged food,and it has implemented all WHO sodium-related best buys for tackling noncom
323、municable diseases.In addition,Kiribati,Philippines,and the Republic of Korea have at least two mandatory measures,but do not implement all the best buys which would result in an uplift to score 4.Kiribati,Mongolia,Philippines,and Republic of Korea have implemented mandatory policies for sodium redu
324、ction alongside mandatory declaration of sodium on pre-packaged food and have therefore reached score 3,policies implemented include public food procurement and service policies(all four Member States),marketing restrictions(Philippines,Republic of Korea),a limit on sodium in food(Kiribati)and front
325、-of-pack labelling(Republic of Korea).Box 14(page 31)describes the mandatory marketing restrictions in the Republic of Korea.In addition,Brunei Darussalam has mandatory public food procurement and service with an underlying nutrient profile model that includes sodium but does not have a mandatory so
326、dium declaration of sodium on all pre-packaged food.Australia,China,Fiji,Japan,New Zealand,and Samoa have mandatory declaration of sodium on pre-packaged food but no other mandatory measure,all of which would result in an uplift to score 3.The largest proportion of Western Pacific Region Member Stat
327、es(41%)are in score 2,with 13 Member States having implemented voluntary policies only,voluntary reformulation targets(Australia,Brunei Darussalam,Fiji,New Zealand,Singapore,Vanuatu),public food procurement and service policies(Australia,Brunei Darussalam,China,New Zealand,Singapore),and front-of-pa
328、ck labelling(Australia,Brunei Darussalam,New Zealand,Singapore),but also other interpretive nutrition labelling(China)and marketing restrictions(Brunei Darussalam).Boxes 3(page 17),9(page 26)and 11(page 28)describe voluntary approaches to reformulation in Australia,front-of-pack labelling in Austral
329、ia and New Zealand,and a media campaign in China,respectively.Seven Member States are in score 1 with only a national policy commitment to reduce sodium intake,while no information was available for Marshall Islands or Niue(Annex 1).Table 6.Sodium reduction policies and other measures implemented in
330、 the Western Pacific RegionAt least two mandatory policies and all WHO sodium related best buys+a declaration of sodium on pre-packaged foodScore 4Malaysia1Score 3At least one mandatory policy+a declaration of sodium on pre-packaged foodKiribati,Mongolia,Philippines,Republic of Korea4Score 2At least
331、 one voluntary policyAustralia,Brunei Darussalam,Cambodia,China,Fiji,Japan,Micronesia(Federated States of),New Zealand,Samoa,Singapore,Tuvalu,Vanuatu,Viet Nam13Score 1A national policy commitment Cook Islands,Lao Peoples Democratic Republic,Nauru,Palau,Papua New Guinea,Solomon Islands,Tonga741RESULT
332、S3 As described in the methods,baseline year of 2019 represents the year of the latest available sodium intake estimates.The Sodium Country Score Card was therefore adjusted to reflect status in 2019.In the period 20192022,three Member States had advanced two scores(Ukraine from score 1 to score 3,a
333、nd Malaysia and Spain from score 2 to score 4)and eight Member States had advanced one score(Algeria,China and Luxembourg from score 1 to score 2,Finland,Indonesia and Mongolia from score 2 to score 3,and Brazil and Mexico from score 3 to score 4).Population dietary sodium intake In 2019,the mean global sodium intake of adults was estimated at 4310 mg/day(10.78 g/day salt)which is more than double