Meeting WHO’s Sodium Benchmarks Would Cut Deaths, Illness, Model Suggests

Fully complying with recommendations set by the World Health Organization (WHO) to lower sodium levels in packaged foods would markedly reduce deaths and new cases of CVD each year, according to an Australian modelling study.

A decade ago, the WHO set a goal of decreasing the mean global sodium intake by 30% by 2025. That equates to a daily intake of less than 2,000 mg per day. In 2021, the WHO followed that recommendation with the publication of global sodium “benchmarks” for individual food categories, a document that was meant to serve as a guide for countries and the food industry for the sodium content in everything from packaged sweets and snacks to soups, sauces, pastas, and bread.

The new study, modelled on the Australian population, implies that meeting those benchmarks could mean big health gains not just for Australia, but for most high-income countries with a Western diet, including the United States, the United Kingdom, New Zealand, Canada, and Denmark, said lead author Kathy Trieu, PhD (University of New South Wales, Sydney, Australia).

“These findings of substantial public health gains that could be achieved through compliance with the WHO sodium benchmarks are generalizable to other countries where packaged foods are commonly consumed and major contributors of sodium in the diet,” Trieu said via email.

While the principal aim of modeling studies like Trieu’s is to help policy makers and food companies understand the impact that decreases in sodium levels across the food supply can have on public health, it can also serve to drive home the message to consumers about what is possible through stricter enforcement of sodium reduction strategies, she added.  

According to the modeling estimates, full compliance with the WHO benchmarks would lower mean adult sodium intake by about 400 mg per day, or 12%. While that figure is important, Trieu and colleagues say it’s not enough: the average Australian needs to cut their sodium intake by 40% to meet the 2,000 mg per day WHO recommendation.

Australia, like many other countries, has their own voluntary, government-adopted sodium targets for packaged foods, although these are far fewer than the 58 comprehensive categories included in the WHO benchmarks.

For Eugene Yang, MD (University of Washington, Bellevue), who was not involved in the study, the modeling estimates are evidence that even small changes in sodium reduction yield big benefits on health and may help achieve better BP control and lower overall BP at a population level.

“There was a threefold improvement in cardiovascular events rate by [following] the World Health Organization benchmarks compared to the Australian benchmarks,” he said. This picture of fewer deaths and serious illness that the Australian study paints should be a global wake-up call to policy makers and the food industry of the importance of tightening up their sodium targets in packaged foods, he added.

CVD Prevention a Key Benefit

In the study, published online today in Hypertension, Trieu and colleagues found that full compliance with the WHO global sodium benchmarks would avert an estimated 1,770 deaths per year, predominantly those due to CVD, followed by stomach cancer, and chronic kidney disease (CKD). The majority (82%) of the avoidable deaths were in individuals age 70 and older, and 61% of them were men. There would also be an estimated 4,500 fewer new cases of CVD, 2,050 fewer new cases of kidney disease, and 350 fewer new cases of stomach cancer per year.

The foods most associated with declines in mortality if their sodium content was reformulated to meet WHO benchmarks were processed meats and fish, which accounted for one-third of all estimated avoidable deaths, followed by breads and bread products, cakes, sweet biscuits, and pastries.

To TCTMD, Trieu said the reductions in sodium levels of packaged foods towards the WHO benchmarks “can be achieved gradually over time to allow for food companies to adjust their products and consumers to adjust their taste; however the sooner the sodium targets can be achieved, the sooner the estimated health benefits can be realized.”

In an accompanying editorial, Rachael M. McLean, PhD (University of Otago, Dunedin, New Zealand), and colleagues note that even though the WHO created “an evidence-based technical package on how countries should implement strategies to reduce dietary sodium intake,” progress in this regard has been variable across the globe, with citizens of most countries still eating well in excess of 2,000 mg of sodium per day.

Adopting the WHO benchmarks, they say, “enables countries to bypass these processes that have already been undertaken by WHO on a global level” and “enables a pro-equity approach, which targets foods widely consumed by all groups in society, rather than requiring individuals to actively change behavior, something often more afforded to those more privileged in society.”

Advocating for Change

Yang said while the modeling study suggests that maybe Australia has not been aggressive enough in the way they adopted sodium targets for packaged foods, they still show evidence of positive steps. While the food industry can’t be forced by government to meet stricter benchmarks “the reality is that even these small changes did have a significant anticipated benefit rate in reducing the rates of mortality as well as cardiovascular events,” he added.

In the US, where initial recommendations from the Food and Drug Administration to the commercial food industry about sodium reduction reformulations lagged behind other countries by decades, the approach has indeed been gradual, with the agency saying it was aiming for 3,000 mg per day initially based on evidence that Americans consume an estimated 3,400 mg of sodium per day. The American Heart Association has been critical of that stance, urging the FDA to further lower their recommendation to 2,300 mg per day.

While inconsistencies in targets are probably never going to go away, Yang said, the real message of the Australian modeling study is the importance of individual countries taking a hard look at their packaged food benchmarks and pressing the food industry to intensifying them as needed to improve the overall health of their populations.

“We are never going to get to a point where you have enforcement or requirement of [food manufacturers] to do that, but the environment is changing to one of a call for action globally on this,” Yang added. “I think we also need more involvement of our societies, like our cardiology societies or medical societies in an advocacy role, to pressure restaurant and consumer food industries to make some of these changes.”