Search

Objective:To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).Design:Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson’s ‘Health Policy Triangle’ to assess the role of context, content, process and actors on the implementation of salt policy.Setting:Argentina, Mongolia, South Africa and Vietnam.Participants:Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.Results:Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.Conclusions:Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

This study aimed to investigate the association between individual and combinations of macronutrients with premature death, CVD and dementia. Sex differences were investigated. Data were utilised from a prospective cohort of 120 963 individuals (57 % women) within the UK Biobank, who completed ≥ two 24-h diet recalls. The associations of macronutrients, as percentages of total energy intake, with outcomes were investigated. Combinations of macronutrients were defined using k-means cluster analysis, with clusters explored in association with outcomes. There was a higher risk of death with high carbohydrate intake (hazard ratios (HR), 95 % CI upper v. lowest third 1·13 (1·03, 1·23)), yet a lower risk with higher intakes of protein (upper v. lowest third 0·82 (0·76, 0·89)). There was a lower risk of CVD with moderate intakes (middle v. lowest third) of energy and protein (sub distribution HR (SHR), 0·87 (0·79, 0·97) and 0·87 (0·79, 0·96), respectively). There was a lower risk of dementia with moderate energy intake (SHR 0·71 (0·52, 0·96)). Sex differences were identified. The dietary cluster characterised by low carbohydrate, low fat and high protein was associated with a lower risk of death (HR 0·84 (0·76, 0·93)) compared with the reference cluster and a lower risk of CVD for men (SHR 0·83 (0·71, 0·97)). Given that associations were evident, both as single macronutrients and for combinations with other macronutrients for death, and for CVD in men, we suggest that the biggest benefit from diet-related policy and interventions will be when combinations of macronutrients are targeted.

Objective:To estimate the proportion of products meeting Fiji government labelling regulations, assess compliance with national Na reformulation targets and examine the Na and total sugar levels in packaged foods sold in selected major supermarkets.Design:We selected five major supermarkets in 2018 and collected the product information and nutritional content from the labels of all packaged foods sold. We organised 4278 foods into fourteen major food categories and thirty-six sub-categories and recorded the proportion of products labelled in accordance with the Fiji labelling regulations. We looked at the levels of Na and total sugar in each food category and assessed how many products complied with the Fiji reformulation targets set for Na. We also listed the companies responsible for each product.Setting:Suva, Fiji.Results:Fourteen percentage of packaged foods in fourteen major categories met Fiji national labelling regulations. Na was labelled on 95·4 % products, and total sugar labelled on 92·4 %. The convenience foods category had the highest Na levels (1699 mg/100 g), while confectionery had the highest content of total sugar (52·6 g/100 g). Forty percentage of eligible products did not meet the proposed voluntary Na reformulation targets.Conclusions:Our findings indicate significant room for improvement in nutrient labelling, as well as a need for further enforcement of reformulation targets and monitoring of changes in food composition. Through enacting these measures and establishing additional regulations such as mandatory front-of-pack labelling, government and food industry can drive consumers towards healthier food choices and improve the nutritional quality of packaged foods in Fiji.

Background Non-communicable diseases (NCDs) have been declared a crisis in the Pacific Islands, and poor diets are a major contributor to this. The COVID-19 pandemic and resulting economic crisis will likely increase the burden on food systems, exacerbating this situation. Pacific Island leaders have been proactive in adopting a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Whilst there is increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. Methods Our 5-year collaborative research project will advance knowledge of how to scale up food policy interventions in the Pacific Islands. The overall aim of this implementation science research project is to test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and to examine factors that will support sustained implementation. We will engage, as partners, government agencies and civil society in Fiji and Samoa, and support the design, implementation and monitoring of a range of evidence-informed interventions aiming to reduce salt and sugar consumption, in the context of on-going health and environmental challenges, such as COVID-19 and climate change. Specific objectives are to: (1) conduct a policy landscape analysis to understand the potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Discussion The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.Contributions to the literature· Poor diets are one of the main contributors to non-communicable diseases. There is increasing evidence to show that food policy interventions (fiscal or regulatory) are an effective way of improving diets, globally. · This project will produce local context-specific evidence for the impact and cost-effectiveness of food policy interventions to improve diets in the Pacific Islands (Fiji and Samoa). It will also produce new insights into what is feasible and which factors contribute most to effective implementation in different contexts.· The findings will provide important insights into gaps in the implementation science literature on food policy implementation, particularly in Small Island Developing States. The project will also make an important contribution globally since the innovative methods of engaging policy makers and monitoring food and health developed through the project may be replicated elsewhere.

The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs). The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures—salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure—were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country’s income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.

BACKGROUND The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required. OBJECTIVES The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation. METHODS Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics. RESULTS The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P

The Global Burden of Disease (GBD) 2010 study estimated national salt intake for 187 countries based on data available up to 2010. The purpose of this review was to identify studies that have measured salt intake in a nationally representative population using the 24‐hour urine collection method since 2010, with a view to updating evidence on population salt intake globally. Studies published from January 2011 to September 2018 were searched for from MEDLINE, Scopus, and Embase databases using relevant terms. Studies that provided nationally representative estimates of salt intake among the healthy adult population based on the 24‐hour urine collection were included. Measured salt intake was extracted and compared with the GBD estimates. Of the 115 identified studies assessed for eligibility, 13 studies were included: Four studies were from Europe, and one each from the United States, Canada, Benin, India, Samoa, Fiji, Barbados, Australia, and New Zealand. Mean daily salt intake ranged from 6.75 g/d in Barbados to 10.66 g/d in Portugal. Measured mean population salt intake in Italy, England, Canada, and Barbados was lower, and in Fiji, Samoa, and Benin was higher, in recent surveys compared to the GBD 2010 estimates. Despite global targets to reduce population salt intake, only 13 countries have published nationally representative salt intake data since the GBD 2010 study. In all countries, salt intake levels remain higher than the World Health Organization's recommendation, highlighting the need for additional global efforts to lower salt intake and monitor salt reduction strategies.

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

Background Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population’s median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. Methods and findings We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%–4.2%) and 1.6% (1.3%–2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%–37.2%) for males and 41.6% (23.9%–53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%–58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. Conclusions This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk., Author summary Why was this study done? CVD burden in low-income and middle-income countries (LMICs) is high and rising. CVD risk estimation using validated risk prediction equations is recommended in most guidelines; however, there are few population-representative analyses of CVD risk and its association with socio-demographic characteristics. Despite guidelines recommending using CVD risk estimates as an essential first step in guiding management practices, the extent to which risk-based approaches are being implemented in LMICs is not well characterised. What did the researchers do and find? We analysed population-representative survey data from 45 LMICs to determine country-specific levels of CVD risk, associations between socio-demographic factors and levels of CVD risk, and adherence to WHO guidelines on use of blood pressure medication. We found high variation in CVD risk profiles, with higher levels of risk in the Europe and the Eastern Mediterranean region and lower levels of risk in sub-Saharan Africa, as well as an inverse association between CVD risk and higher education and employment in most countries. We found an underuse of medicines in people at elevated CVD risk across all countries (only 24.2% of males and 41.6% of females at high CVD risk are taking guideline-recommended BP medication) and an overuse of medicines in people at lower levels of CVD risk, with 47% of all BP medication being used by people at low CVD risk without a guideline indication for use. What do these findings mean? There is large variation in CVD risk across LMICs, and an inverse association between CVD risk and higher education and employment in most countries. There is an overuse of medicines in people at lower levels of CVD risk and an underuse of medicines in people at elevated CVD risk across all countries. The large heterogeneity of the findings in this study reflects varying country contexts. Country-specific targeted policies are needed to improve the identification and management of those at highest CVD risk.

BACKGROUND: To inform the interpretation of dietary data in the context of sex differences in diet-disease relations, it is important to understand whether there are any sex differences in accuracy of dietary reporting.OBJECTIVE: To quantify sex differences in self-reported total energy intake (TEI) compared with a reference measure of total energy expenditure (TEE).METHODS: Six electronic databases were systematically searched for published original research articles between 1980 and April 2020. Studies were included if they were conducted in adult populations with measures for both females and males of self-reported TEI and TEE from doubly labeled water (DLW). Studies were screened and quality assessed independently by 2 authors. Random-effects meta-analyses were conducted to pool the mean differences between TEI and TEE for, and between, females and males, by method of dietary assessment.RESULTS: From 1313 identified studies, 31 met the inclusion criteria. The studies collectively included information on 4518 individuals (54% females). Dietary assessment methods included 24-h recalls (n = 12, 2 with supplemental photos of food items consumed), estimated food records (EFRs; n = 11), FFQs (n = 10), weighed food records (WFRs, n = 5), and diet histories (n = 2). Meta-analyses identified underestimation of TEI by females and males, ranging from -1318 kJ/d (95% CI: -1967, -669) for FFQ to -2650 kJ/d (95% CI: -3492, -1807) for 24-h recalls for females, and from -1764 kJ/d (95% CI: -2285, -1242) for FFQ to -3438 kJ/d (95% CI: -5382, -1494) for WFR for males. There was no difference in the level of underestimation by sex, except when using EFR, for which males underestimated energy intake more than females (by 590 kJ/d, 95% CI: 35, 1,146).CONCLUSION: Substantial underestimation of TEI across a range of dietary assessment methods was identified, similar by sex. These underestimations should be considered when assessing TEI and interpreting diet-disease relations.

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

IntroductionDiet is an important modifiable risk factor for many chronic diseases. Measurement of dietary intake usually relies on self-report, subject to multiple biases. There is a need to understand gender differences in the self-report of dietary intake and the implications of any differences in targeting nutrition interventions. Literature in this area is limited and it is currently unknown whether self-report dietary assessment methods are equally accurate for women and men. The aim of this systematic review is to determine whether there are differences by gender in reporting energy intake compared with a reference measure of total energy expenditure.Methods and analysisA comprehensive search of published original research studies will be performed in MEDLINE, Scopus, Web of Science, EMBASE, CINAHL and Cochrane library. Original research studies will be included if they were conducted in free-living/unhospitalised adults and included a measure for both women and men of (a) self-reported energy intake and (b) total energy expenditure by doubly labelled water. One author will conduct the electronic database searches, two authors will independently screen studies, conduct a quality appraisal of the included studies using standardised tools and extract data. If further information is needed, then study authors will be contacted. If appropriate, a random-effects meta-analysis will be conducted, with inverse probability weighting, to quantify differences in the mean difference in agreement between reported energy intake and measured energy expenditure between women and men, by self-report assessment method. Subgroup analyses will be conducted by participant factors, geographical factors and study quality.Ethics and disseminationAll data used will be from published primary research studies or deidentified results provided at the discretion of any study authors that we contact. We will submit our findings to a peer-reviewed scientific journal and will disseminate results through presentations at international scientific conferences.PROSPERO registration numberCRD42019131715.

Background Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk. Methods From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013–2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences. Results Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value p-valuep-value = 0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value = 0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value = 0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes. Conclusion Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.

Additional file 1: Table S1. Number and percent of individuals with missing data on outcome, independent variables and confounders*, overall and by country. Table S2. Survey characteristics. Table S3. Characteristics of individuals with data on dietary behaviours, and data on waist circumference (n = 23,273) hypertension (n = 24,011), diabetes (n = 17,724) status. Table S4. Prevalence of dietary behaviours among participants with data on waist circumference (n = 23,273) hypertension (n = 24,011), or diabetes (n = 17,724) status. Figure S1. a. Weighted proportion of males (n = 8551) reporting positive dietary behaviours, in seven low-and middle-income countries. b. Weighted proportion of females (n = 14,960) reporting positive dietary behaviours, in seven low-and middle-income countries. Figure S2. a. Percentage (95% confidence interval) of males with undiagnosed hypertension, by the self-report of salt behaviour on a seven point scale*. b. Percentage (95% confidence interval) of females with undiagnosed hypertension, by the self-report of salt behaviour on a seven point scale*. Figure S3. a. Percentage (95% confidence interval) of males with undiagnosed hypertension, by the self-report of salt behaviour on a four point scale*.b. Percentage (95% confidence interval) of females with undiagnosed hypertension, by the self-report of salt behaviour on a four point scale*.

The aim of the current review was to examine the scope of studies published in the Science of Salt Weekly that contained a measure of self‐reported knowledge, attitudes, and behavior (KAB) concerning salt. Specific objectives were to examine how KAB measures are used to evaluate salt reduction intervention studies, the questionnaires used, and whether any gender differences exist in self‐reported KAB. Studies were reviewed from the commencement of Science of Salt Weekly, June 2013 to the end of August 2017. Seventy‐five studies had relevant measures of KAB and were included in this review, 13 of these were salt‐reduction intervention‐evaluation studies, with the remainder (62) being descriptive KAB studies. The KAB questionnaires used were specific to the populations studied, without evidence of a best practice measure. 40% of studies used KAB alone as the primary outcome measure; the remaining studies used more quantitative measures of salt intake such as 24‐hour urine. Only half of the descriptive studies showed KAB outcomes disaggregated by gender, and of those, 73% showed women had more favorable KAB related to salt. None of the salt intervention‐evaluation studies showed disaggregated KAB data. Therefore, it is likely important that evaluation studies disaggregate, and are appropriately powered to disaggregate all outcomes by gender to address potential disparities.

This periodic review aims to identify, summarize, and appraise studies relating to the implementation of salt reduction strategies that were published between September 2016 and February 2017. A total of 41 studies were included as relevant to the design, assessment, and implementation of salt reduction strategies, and a detailed appraisal was conducted on the seven studies that evaluated the impact of salt reduction strategies. Of these, three were national studies or included large populations and four were conducted in communities with small participant sample sizes. Each study used a different strategy for reducing salt intake varying from category‐specific sodium targets for packaged food to use of a low‐sodium salt substitute to behavior change interventions. Four studies found statistically significant decreases in dietary salt intake and one study showed statistically significant decreases in mean sodium density of packaged food products. Four of the seven studies used either spot or 24‐hour urine samples to measure dietary salt intake and five were conducted in East or Southeast Asia—two of which were in low‐ and middle‐income countries. Study quality varied among the seven studies and all except one had one or more risks related to bias.

The Victorian Salt Reduction Partnership (VicSalt Partnership) was launched in 2015, bringing together health and research organisations to develop an action plan for salt reduction interventions at a state level. A comprehensive evaluation was designed to assess the impact of the resulting four-year intervention strategy. As part of the process evaluation, semi-structured interviews were undertaken with stakeholders in March&ndash, May 2017, to understand perceived barriers and enablers to effective strategy implementation. Data were coded in relation to the key topic areas of the interviews with an inductive method used to analyse themes within topics. Seventeen stakeholders were contacted, 14 completed an interview, five from state government or statutory agencies, four from non-government funded organisations, four from research organisations and one from the food industry. Twelve were members of the VicSalt Partnership and two were informal collaborators. Most stakeholders viewed the VicSalt Partnership as a positive example of working collaboratively, and said this was essential for raising awareness of the importance of salt reduction with consumers, the food industry, and the government. Challenges relating to engaging the food industry and federal government through a state-led initiative were identified. New approaches to overcome this, such as forming clear &ldquo, asks&rdquo, to government and committing industry to &ldquo, pledges&rdquo, on reformulation were suggested. Stakeholder interviews and qualitative analysis have provided a range of important insights into barriers and enablers, many of which have already been used to strengthen intervention implementation. The evaluation of the VicSalt Partnership is ongoing and the program is expected to provide a wealth of lessons for state-led interventions to reduce salt intake in Australia and globally.

ObjectivePacific Island countries are experiencing a high burden of diet-related non-communicable diseases; and consumption of fat, sugar and salt are important modifiable risk factors contributing to this. The present study systematically reviewed and summarized available literature on dietary intakes of fat, sugar and salt in the Pacific Islands.DesignElectronic databases (PubMed, Scopus, ScienceDirect and GlobalHealth) were searched from 2005 to January 2018. Grey literature was also searched and key stakeholders were consulted for additional information. Study eligibility was assessed by two authors and quality was evaluated using a modified tool for assessing dietary intake studies.ResultsThirty-one studies were included, twenty-two contained information on fat, seventeen on sugar and fourteen on salt. Dietary assessment methods varied widely and six different outcome measures for fat, sugar and salt intake – absolute intake, household expenditure, percentage contribution to energy intake, sources, availability and dietary behaviours – were used. Absolute intake of fat ranged from 25·4 g/d in Solomon Islands to 98·9 g/d in Guam, while salt intake ranged from 5·6 g/d in Kiribati to 10·3 g/d in Fiji. Only Guam reported on absolute sugar intake (47·3 g/d). Peer-reviewed research studies used higher-quality dietary assessment methods, while reports from national surveys had better participation rates but mostly utilized indirect methods to quantify intake.ConclusionsDespite the established and growing crisis of diet-related diseases in the Pacific, there is inadequate evidence about what Pacific Islanders are eating. Pacific Island countries need nutrition monitoring systems to fully understand the changing diets of Pacific Islanders and inform effective policy interventions.

High sodium intake increases blood pressure and consequently increases the risk of cardiovascular diseases. In Australia, the best estimate of sodium intake is 3840 mg sodium/day, almost double the World Health Organization (WHO) guideline (2000 mg/day), and processed meats contribute approximately 10% of daily sodium intake to the diet. This study assessed the median sodium levels of 2510 processed meat products, including bacon and sausages, available in major Australian supermarkets in 2010, 2013, 2015 and 2017, and assessed changes over time. The median sodium content of processed meats in 2017 was 775 mg/100 g (interquartile range (IQR) 483&ndash, 1080). There was an 11% reduction in the median sodium level of processed meats for which targets were set under the government&rsquo, s Food and Health Dialogue (p &lt, 0.001). This includes bacon, ham/cured meat products, sliced luncheon meat and meat with pastry categories. There was no change in processed meats without a target (median difference 6%, p = 0.450). The new targets proposed by the current government&rsquo, s Healthy Food Partnership capture a larger proportion of products than the Food and Health Dialogue (66% compared to 35%) and a lower proportion of products are at or below the target (35% compared to 54%). These results demonstrate that voluntary government targets can drive nutrient reformulation. Future efforts will require strong government leadership and robust monitoring and evaluation systems.