Modeling the health impact of legislation to limit the salt content of bread in Portugal: A macro simulation study.

Background: Excessive salt consumption-associated with a range of adverse health outcomes-is very high in Portugal, and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4 g salt per 100 g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0/100 g by 2022, however the legislation was vetoed by the European Commission on free-trade grounds.
Aims: To estimate the health impact of subjecting imported and traditional breads to the current 1.4 g threshold, and to model the potential health impact of implementing the proposed 1.0 g threshold.
Methods: We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modeling tool to estimate the number of salt-related deaths that would have been averted in 2016 (the latest year for which all data were available) from; (1) Extending the 1.4 g threshold to all types of bread, and (2) Applying the 1.0 g threshold to all bread sold in Portugal. We used Monte Carlo simulations to generate confidence intervals.
Results: Applying the current 1.4 g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95% CI: 43-172). Lowering the current threshold from 1.4 to 1.0 g and applying it to all bread products would reduce daily salt consumption by 3.6 tons per day, saving an estimated 286 lives a year (95% CI: 123-454).
Conclusions: Salt is an important risk factor in Portugal and bread is a major source. Lowering maximum permissible levels and removing exemptions would save lives. The European Commission should revisit its decision on the basis of this new evidence.
Competing Interests: Author FA was the Portuguese Secretary of State for Health until October 2018. Authors FG-d-S and DC-e-S were members of the Portuguese Secretary of State for Health office until October 2018. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
(Copyright © 2022 Goiana-da-Silva, Cruz-e-Silva, Rito, Lopes, Muc, Darzi, Araújo, Miraldo, Morais Nunes and Allen.)