An overview of salt intake reduction efforts in the Gulf Cooperation Council countries

Introduction

Non-communicable diseases (NCDs) are the leading causes of premature death in the 21^st century, and represent a threat to human health and economic growth (1). Currently, 39 million people die each year from NCDs, principally, cardiovascular disease (CVD), cancers, chronic respiratory disease, and diabetes. The main risk factor for the global disease burden is raised blood pressure and is estimated to cause 9.4 million deaths each year. This is more than half the estimated 17 million annual deaths caused by CVD (1,2).

The 2010 World Health Organization’s (WHO) global status report on NCDs urged Member States to take immediate actions in reducing salt intake (1). Salt reduction was recommended as one of the top three priority actions to reduce premature mortality from NCDs by 25% by 2025 (3). To achieve this, the WHO recommended a 30% reduction in salt intake by 2025 with an eventual target of 5 g per day for adults and lower levels for children based on calorie intake (1). They also recommended reducing the salt content of food as an effective measure to achieve accelerated results in saving lives, preventing cases of disease, and avoiding costs (2,4). This position has since been endorsed by the 2011 Political Declaration of the UN High-Level Meeting (UN HLM) on NCDs (5) and has led to the development and adoption of the Global Monitoring Framework and Voluntary Global Targets for the Prevention and Control of NCDs. As a result, Member States have agreed upon a global target of a 30% gradual reduction in mean salt intake by 2025 (5,6).

The Gulf Cooperation Council (GCC) includes six countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates (UAE). In these countries populations lead a sedentary lifestyle, where high blood pressure (Figure 1) and obesity (Figure 2) are known to be major contributing risk factors to NCDs (7). Thus, it is not surprising that CVD is the main cause of morbidity and mortality in the Gulf region (8).

Figure 1 Prevalence of high blood pressure in GCC countries. GCC, Gulf Cooperation Council.

Figure 2 Prevalence of obesity in GCC countries. GCC, Gulf Cooperation Council.

The estimated total deaths in GCC countries caused by NCDs range between 65% and 78%, with the highest estimates in Bahrain and Saudi Arabia and the lowest in Oman and Qatar, respectively (7). In the Eastern Mediterranean Region (EMR), current salt intake is high, with an estimated average intake of >12 g per person per day in most countries. This is more than double the amount recommended by the WHO. Cereal products, in particular bread, are a popular staple food in GCC countries, and contribute a major part of salt in the diet. When bread (of the same type) was compared between countries in the EMR, a wide variation of salt content was observed (Table S1). Therefore, a reduction of the salt level in bread was sought as an effective means to reduce the NCD burden in the region. This article gives an overview of the efforts and initiatives taken by each country in the GCC region to reduce the salt intake and achieve WHO targets.

Table S1 Content of salt in bread highly consumed in Eastern Mediterranean region
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Salt reduction activities in GCC countries

In 2014, the GCC Executive Board of Health Ministers convened a meeting in Kuwait to discuss reducing the growing burden of NCDs in the region (8). The main risk factors addressed were salt and fat intake reductions to meet the 2025 targets. This meeting urged countries in the region to develop a framework of action with indicators that can be adopted, implemented, monitored and evaluated. The outcome of this meeting was the release of the Kuwait Declaration for the Control of Non-Communicable Diseases (8) in which Member States agreed to commit to its recommendations.

Kingdom of Bahrain

Bahrain is an island located near the western shores of the Arabian Gulf with a population of ~1,300,000 people. According to the WHO, CVDs account for 26% of the total deaths in Bahrain (7). The Nutrition Section, Ministry of Health (MOH), is the main governmental body responsible for salt intake reduction activities.

In their efforts to establish baseline data on sodium intake among the Bahraini population, a study was conducted by the Nutrition Section to assess urinary sodium levels. A spot urine test indicated an average of 136 mmol/L, and 122 mmol/L of urinary sodium among children (n=128) and adults (n=64), respectively (9). These results were inaccurate as the sample size was not representative of the population.

In 2014, a pilot study was conducted to determine the salt intake in a sample of 50 Bahraini adults aged 20-40 years, by collecting 24-hour urinary sodium (10). Results showed that only 8% of males and 10% of females were found to have relatively high concentration of urinary sodium. However, further analysis is needed due to the small sample size.

Furthermore, another pilot study was conducted, in collaboration with EMRO, to assess the salt content of bread (10). Twenty samples were collected from different bakeries throughout Bahrain. The average salt content was found to be approximately 90,000 ppm; this was much higher than the WHO recommended levels. The Nutrition Section has proposed an action plan for an annual 10% salt reduction in bread. This is awaiting approval from the MOH.

Approximately 70% of the bread in Bahrain is produced by the Bahrain Flour Mills Company (BFMC), which follows standardized recipes for the different types of bread produced. The smaller proportion of bread sold in the market is produced by privately owned bakers. No data is available on the amount of salt added to the bread. Salt is added to the flour before mixing the dough. The food labelling of bread is only included on bread produced by the BFMC. It includes the calories and macronutrient content but does not indicate the salt content.

A ministerial decree was formulated in 2014 to establish a multisectoral committee, which aims to reduce salt in bread products. The objective of this committee is to set up a strategy with an action plan that includes:

• Reducing salt in the bakery products;
• Enforcing food labeling to include salt content;
• Developing a legislation and monitoring its implementation.

Kuwait

Kuwait lies on the northwestern tip of the Arabian Gulf. The total population is ~4,100,000 million people (11). According to the WHO, CVDs account for 41% of the total deaths. The Food and Nutrition Administration (FNA) part of the Ministry of Health is the main governmental body in charge of overseeing salt reduction activities.

It is critical to determine the amount of salt consumed before any intervention is implemented. Two studies analyzing food consumption in Kuwait (12,13) found the average salt intake to be within 8-10 g per day. This range may be an underestimate as not all food items were included in the studies (Table 1).

Table 1 Summary of national projects measuring sodium intake in Kuwait
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Data from these studies provided information on the main food sources of salt in the Kuwaiti diet, indicating that salt was mainly added during food preparation at home. This was shown to be the main source of salt intake.They also showed that bread consumption was the second main source of salt (Figure 3). Further research is needed to ensure the accuracy of data for future actions. Kuwait is currently at the stage of designing a study to determine salt intake by using the gold standard of assessing 24-hour urinary sodium.

Figure 3 Major sources of salt in Kuwait.

The majority of bread in Kuwait is produced locally by Kuwait Flour Mills and Bakeries Company (KFMBC). This factory accounts for 80% of the total bread production in Kuwait. The factory follows standardized recipes for the different types of bread produced. Salt is mixed with the flour before water is added to make the dough. The food labelling is included on the bread produced by the company and only includes the calorie and macronutrient content.

The MOH in partnership with KFMBC decided to implement the WHO recommendations regarding reducing salt intake. A 10% reduction of salt in bread was achieved in March 2013. This was followed by another 10% reduction 6 months later, in August of the same year. By October, 2013 almost all types of bread produced by the company, with the exception of one traditional variety, had a 20% salt reduction. An example of the regular monitoring of salt in bread is shown in Figure S1.

Figure S1 Kuwait.

Kuwait imports more than 95% of consumed food. Processed foods such as breakfast cereals, cheese, chips and meat, account for a significant amount of salt in the Kuwaiti diet. Some of these food items are sometimes highly consumed, for example, chips by children. This was recognized as an opportunity to further engage the private sector. A plan to advocate partnership and engage food companies with health awareness activities was put together. The major aims included:

• Introducing salt reduction strategies and its beneficial impact on the health of the population;
• Emphasizing the critical role of the private sector in the actions to be taken;
• Requesting information on the current level of salt in locally produced and imported foods;
• Working with the private sector on an effective and applicable plan of action for the gradual reduction of salt.

A similar approach with the same aims was taken by meeting with the largest restaurant franchise operators in Kuwait. The objectives of the meeting were to open dialogue with the companies; to highlight the health benefits of salt reduction; and, to emphasize the feasibility with no financial losses. This is currently in progress.

Sultanate of Oman

Oman lies on the southeastern coast of the Arabian Peninsula. Its population size is approximately three million. According to the WHO, CVDs account for 33% of the total deaths (7). The Ministry of Health, Oman, is the main governmental body that oversees salt reduction activities.

The National Nutrition Survey based on the 24-hour dietary recall suggested the average intake of salt between 11-12 g per day (14). In order to reduce the consumption of salt to the levels specified by WHO, initiatives are being planned, though are still in their initial stages. Currently, the MOH is working towards reducing salt levels in commonly consumed foods; mainly focusing on highly salted foods such as bread, cheese, and processed meats.

According to the director of Nutrition, Ministry of Health, there is no standardized recipe for bread of the same kind, thus, the salt content varies within the same bakery chain (Table S2).

Table S2 Food chemistry analysis
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Future interventions for the reduction of salt include:

• Establishing a national taskforce for salt reduction;
• Achieving 10% reduction of salt in the bread within 6-8 months, 2014;
• Identifying of the main sources of salt in the diet;
• Reviewing and revising national food standards for bread to reflect the recommended minimum levels of salt content in bread;
• Conducting studies to monitor the intake of sodium using the 24-hour urinary assessment;
• Establishing salt standards for compliance by all bakers.

Qatar

Qatar lies on the northeastern coast of the Arabian Peninsula. It has a population size of approximately 2 million people. According to WHO, CVDs account for 24% of total deaths (7). The Supreme Council of Health (SCH) is the main governmental body that oversees salt reduction activities in Qatar.

A national project by the SCH found that the main source of salt in the diet was from bread and other baked products (15). The council, in collaboration with EMRO planned initiatives to reduce salt in bread by 30% (Table S3).

Table S3 GCC salt reduction plan and action for bread
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The main national bakery (Mesaieed Bakery, or Qbake) was first contacted as it is the main producer of bread. It was requested to send the samples of the commonly consumed bread namely, the brown Arabic bread, small, (70 g × 4 pieces =280 g), white Arabic bread, small, (70 g × 10 pieces =700 g) and brown and white Lebanese bread, large, (140 g × 5 pieces =700 g) to the Central Food Laboratory. The results showed a 10% salt content reduction.

Before implementing another 10% reduction in salt content, the SCH is testing if a 20% salt reduction in different types of bread will have an effect on taste and palatability (to reach 0.90 kg per 100 kg for all bread types). Samples showed a wide range of salt levels between the different bakeries (the results ranged between 0.20% and 1.80% sodium content). Bakeries have been notified to reduce the salt content by 10% and the samples are now being tested to see if this has been achieved. This would establish a baseline for the gradual reduction of the added salt by 30%.

Kingdom of Saudi Arabia (KSA)

Saudi Arabia is the largest Arab state in Western Asia, constituting the bulk of the Arabian Peninsula. It has a population size of approximately 28 million people. Data reported in the WHO NCD country profile showed that CVDs account for 46% of the total deaths in the country (7). The Ministry of Health, is the main governmental body that oversees salt reduction activities.

During the recent Gulf Nutrition Committee Meeting held in Kuwait (February 2015), Saudi Arabia reported that salt intake reduction efforts are in their preliminary stages. Similar to other GCC countries, reduction of the salt content in bread is being targeted. As a result, the MOH proposed to pass a decree aiming to reduce salt by 10% annually until a target of 30% reduction is achieved. Bakeries in the country were contacted and several workshops were held to introduce this initiative. The MOH expressed challenges of reducing salt in the popular traditional breads as it is often added according to the baker’s preference. Therefore, while initial steps are underway, coverage and monitoring of implementation will remain a challenge.

The United Arab Emirates (UAE)

The UAE is located on the southeast end of the Arabian Peninsula, and has a total population of approximately nine million people (7). According to the WHO, CVDs account for 30% of the total deaths in the UAE. The Ministry of Health, UAE is the main governmental body in charge of overseeing salt reduction activities.

The MOH is in its initial stages of implementing its salt intake reduction strategy. Currently it is identifying the main producers of bread to review the current situation regarding bread production, distribution, and the use of standardized recipes. The aim is to set a plan of action for the gradual reduction of salt in bread.

Conclusions

Countries of the GCC are showing willingness to comply with the WHO recommendations to reduce salt intake so as to reach the overall goal of reducing the burden of NCDs. However, there are challenges faced, including lack of political commitment, inexperience and shortage of qualified human resources. They are at the early stages of salt intake reduction. The efforts in the GCC countries range from the 20-30% salt reduction strategy in bread, to building partnerships with the private sector, to the very early stages of planning.

Acknowledgements

We would like to thank our colleagues. Dr. Nadia Al Ghareb, Head of Nutrition Unit, Ministry of the Kingdom of Bahrain; Dr. Samia Al Ghannami, Director of Nutrition Department, Ministry of Health, Sultanate of Oman; Dr. Al-Anude Al Thani, Manager Health Promotion and NCDs, Public Health Department, Ministry of Health, Qatar; Dr. Mishary Al Dakheel, Director of Nutrition, Ministry of Health, Kingdom of Saudi Arabia; Mrs. Latifa, Head of Nutrition Unit, Ministry of Health, United Arab Emirates. We also would like to extend our thanks to Engineer Mrs. Ibtihal Al Salem, Labs and Quality Manger, Kuwait Flour Mills and Bakeries Company, Kuwait and Mrs. Wafaa Al Jowhar, Head of Chemical Laboratory, Ministry of Health, Kuwait.

Disclosure: The authors declare no conflict of interest.

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