Sodium content and labelling of processed and ultra-processedfood products marketed in Brazil

Carla Adriano Martins12 Anete Arauacutejo de Sousa123 Marcela Boro Veiros123David Alejandro Gonzaacutelez-Chica13 and Rossana Pacheco da Costa Proenccedila1231Nutrition Post-Graduate Program Federal University of Santa Catarina Campus Universitaacuterio Trindade88040-900 Florianoacutepolis SC Brazil 2Nutrition in Foodservice Research Centre (NUPPRE) Federal Universityof Santa Catarina Florianoacutepolis SC Brazil 3Nutrition Department Federal University of Santa CatarinaFlorianoacutepolis SC Brazil

Submitted 3 August 2013 Final revision received 5 July 2014 Accepted 15 July 2014

AbstractObjective To analyse the Na content and labelling of processed and ultra-processed food products marketed in BrazilDesign Cross-sectional studySetting A large supermarket in Florianopolis southern BrazilSubjects Ingredient lists and Na information on nutrition labels of all processedand ultra-processed pre-prepared meals and prepared ingredients used in lunchor dinner available for sale in the supermarketResults The study analysed 1416 products distributed into seven groups andforty-one subgroups Five products did not have Na information Most products(58middot8 95 CI 55middot4 62middot2 ) had high Na content (gt600 mg100 g) In 78middot0 ofthe subgroups variation in Na content was at least twofold between similarproducts with high and low Na levels reaching 634-fold difference in thelsquogarnishes and othersrsquo subgroup More than half of the products (52middot0 95 CI48middot2 55middot6 ) had at least one Na-containing food additive There was norelationship between the appearance of salt on the ingredients list (first to thirdposition on the list) and a productrsquos Na content (high medium or low P= 0middot08)Conclusions Most food products had high Na content with great variationbetween similar products which presents new evidence for reformulationopportunities There were inconsistencies in Na labelling such as lack ofnutritional information and incomplete ingredient descriptions The position of salton the ingredients list did not facilitate the identification of high-Na foods Wetherefore recommend a reduction in Na in these products and a review ofBrazilian legislation

KeywordsSodium

Food labelsProcessed foods

Consumer

Processed food products are a major source of Na incommon diets and the increased consumption of theseproducts has become a public health problem due to theirhigh Na content(1ndash8) which is related to increased risk ofdeveloping chronic non-communicable diseases(6)

Among processed foods pre-prepared meals andprepared ingredients (classified by Monteiro et al(9) asprocessed and ultra-processed food products) are higherin Na compared with fresh foods(10) In the USA mixeddishes constitute 23 of the populationrsquos total Na intake(11)In Brazil an increase in processed food purchases wasobserved between 1974 and 2008 amounting to 37for prepared foods and processed mixtures 80 forpre-prepared meals and 300 for sausages(1213)

For Brazilians these types of food product are increasinglybeing incorporated into everyday meals including lunch

and dinner replacing andor complementing their basicdiet which is characterized by rice beans meat andsalad(14ndash16) The average Brazilian consumes 3200 mg Nadwhich is higher than the maximum intake recommended bythe WHO and the FAO(517)

Faced with increasing salt and Na consumption amongtheir populations(3) countries around the world are takingmeasures to reduce the intake of this nutrient In thiscontext food labelling has been used as an importantstrategy to inform consumers and restrict Na intake(18)

Labelling is recommended in the WHO Global Strategyon Diet Physical Activity and Health(19) as a tool to sup-port food choices at the time of purchase and in order tofulfil its role the presentation of mandatory information onlabels must be clear legible standardized and easilycomprehensible for consumers(20)

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HealthNutrition

Public Health Nutrition page 1 of 9 doi101017S1368980014001736

Corresponding author Email rossanacostaufscbr copy The Authors 2014

In Brazil nutrition labelling on packaged foods anddrinks (including information about Na) has been man-datory since 2001(21) This information must be describedin milligrams per serving with the percentage daily value(DV) calculated according to an average of 2400 mg NadValues less than 5 mg Na100 g food are consideredinsignificant amounts ie lsquozero sodiumrsquo

(2223) It is alsomandatory to present a list of ingredients in descendingorder according to the proportions used and food addi-tives must be described directly after the foods(24) Thusthe Brazilian Dietary Guidelines recommend checking theposition of salt in the ingredients list on processed foods toinform about salt content(25) since the product couldpotentially have a high concentration of this substancewhen it appears as one of the first ingredients(25ndash27)

Although labelling is an important tool for reducing thepopulationrsquos Na intake(1828) it has hardly been exploredscientifically in Brazil The high Na content and highvariability among similar products sold in supermarketshas long been recognized(82930) Knowing these contents(and their variations) is important for defining public policyas exemplified by successful initiatives for reformulationaimed at reducing the Na content in food productsmarketed in several countries(18283132) However there iscurrently no good scientific evidence on the Na content(and its variation) in processed foods marketed in BrazilGiven that pre-prepared meals and prepared ingredientscontribute to increased Na intake by the population(1128ndash30)

and that an increase in the purchase of these products bythe Brazilian population has been observed(101216) thepresent study analysed the labelling and Na content ofprocessed and ultra-processed pre-prepared meals andprepared ingredients marketed in Brazil and used in mainmeals specifically lunch or dinner

Methods

Data collectionThe present study was cross-sectional in design andevaluated Na labelling of processed food products sold ina supermarket in the city of Florianopolis southern BrazilThe supermarket was chosen intentionally and belongs toone of the ten largest supermarket chains in Brazil(33) withtwenty-six stores in the southern region of Brazil six ofwhich are located in Florianopolis The products sold inthis store are similar to those sold in other large super-market chains throughout the country The data werecollected from October to December 2011 The super-market manager authorized the research

Collection of label information was carried out with apre-tested instrument for the following analysis variables(i) product identification (ii) ingredients list (appearanceand position of salt on the list compound ingredients andNa-containing food additives appearing on the list) and(iii) Na information (Na in the nutritional information serving

size in grams and Na content in milligrams per serving)For the purpose of the study a compound ingredientwas defined as any ingredient included on the list that iscomposed of two or more ingredients(24) Food additivescontaining Na were identified using the specific Brazilianresolution for food additives(34) and Mercosulrsquos HarmonizedGeneral List of Food Additives and Their FunctionalClasses(35)

The data collection team received training and partici-pated in the instrumentrsquos pilot test For quality controlinformation on two key questions (Na content in milligramsper serving and position of first appearance of salt on theingredients list) was collected twice for 3middot2 of the foodsanalysed (n 44) According to the BlandndashAltman test thedifference in means for the variable lsquoNa content in milligramsper servingrsquowas 0middot05 mg (interval of plusmn 2 SD of minus0middot5 and 0middot6)while the κ value for the variable lsquoposition of the firstappearance of salt on the ingredients listrsquo was 1middot00

Inclusion criteria for food products in the studyThe study included all those food products covered underBrazilian nutrition labelling legislation(23) which have thefollowing characteristics (i) appearance of Na on theingredients list (ii) classified as processed or ultra-processedfood products (iii) pre-prepared meal or prepared ingre-dients and (iv) habitually used by the Brazilian populationin lunch and dinner meals(5141536ndash38)

To assess the true variability in Na content for each typeof specific product products that did not include Na amongtheir ingredients were only included in the sample whenother products with similar characteristics contained thisingredient Information on the packaging of identical pro-ducts of different sizes was recorded separately becausetheir ingredients lists also differed Products habitually usedby the Brazilian population in lunch and dinner meals weredefined based on Brazilian literature(5141536ndash38) Breadwas not included in the analyses as Brazilians do notcustomarily eat these products in the meals studied Wealso excluded products that were fractionated labelled andmarketed by the supermarket itself since such products arenot required to be labelled in Brazil(23)

Statistical treatment and analysis of dataThe collected data were entered into two separatedatabases and later checked for errors and validated inEpiDatareg 3middot1 (EpiData Association Odense Denmark)The products were distributed into seven groups andforty-one subgroups predefined by Brazilian nutritionlabelling legislation to describe serving sizes for packagedfoods(22) Since no product analysed in the present studywas part of Group VII of this legislation (Group VII Sugarand products that provide energy from carbohydrates andfats) this group is not reported in the analyses A quantityequivalence of Na in milligrams per 100 g or 100ml offood was determined for all the products based on servingsize information Na content in milligrams per 100 g

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HealthNutrition

2 CA Martins et al

or 100 ml of food was classified as high content (gt600 mgNa) medium content (gt120 and le 600 mg Na) and lowcontent (le120mg Na) according to the Traffic Light Labelsof the UK Food Standards Agency(39) The first appearanceof salt on the ingredients list was treated as a dichotomousvariable (first to third position fourth position or more)

We conducted a descriptive statistical analysis pre-senting absolute and relative frequency median Nacontent percentiles and relationships between subgrouppercentiles Data dispersion was presented in the 2nd and98th percentiles (P2ndashP98) due to the asymmetry of thevariable lsquoNa content in milligrams per 100 g or 100ml offoodrsquo and to have an overview of information variabilitywithout having the products with extreme values (n 55)influence the results This interval therefore represents thedispersion of 96 of the food products The ratio betweenthe 98th and 2nd percentiles was assessed based on thesevalues with the aim of establishing the differences in Nacontent between similar products In order to facilitatecalculation of the P98P2 ratio for products containing0mg Na100 g the value of 5 mg Na100 g was usedwhich is an amount defined as insignificant by Braziliannutrition labelling legislation(23)

A χ2 test was used to assess the association betweenproduct Na content and the first appearance of salt on theingredients list Due to infeasibility for inclusion in thisanalysis the following products were excluded from thisanalysis (i) those that included salt as their main ingre-dient (complete seasonings and those prepared for brothn 103) since none of these products would be consumeddirectly affecting interpretation of the data (ii) those thatdid not include salt on the ingredients list (n 100) and(iii) those that did not have Na information on the nutritionlabel (n 5)

The statistical software package Statareg version 11middot0 wasused for the statistical analyses with Plt 0middot05 consideredindicative of statistical significance

Results

Of the 4538 Na-containing processed food productsavailable for sale at the supermarket 1416 were classed asprocessed and ultra-processed pre-prepared meals andprepared ingredients used for lunch and dinner There-fore the present study analysed 1416 products by 211different manufacturers ndash 87middot6 of the products havingbeen produced in Brazil The other products were fromArgentina (n 35) Italy (n 27) Spain (n 24) Germany(n 22) the USA (n 21) Peru (n 10) Uruguay (n 7) Belgium(n 5) Chile (n 5) France (n 5) China (n 4) Mexico (n 4)Poland (n 3) Portugal (n 2) and Ecuador (n 1)

Nutritional informationOf the products analysed five (0middot4 ) did not include Nainformation on the nutrition label The remaining 1411

products were distributed into seven groups and forty-onesubgroups

Classification of Na content (mg100 g or 100ml)according to the UK Food Standards AgencyOf all the products with Na nutrition information (n 1411)58middot8 (95 CI 55middot4 62middot2 ) were classified as having ahigh Na content (gt600mg100 g or 100ml) and 7middot0 (95 CI 2middot9 14middot2 ) were classified as having low Nacontent (le120 mg100 g or 100ml)(39) In the Na contentclassification by food group the majority of productsincluded in groups VI (98middot4 ) V (70middot0 ) I (64middot7 ) VIII(61middot7 ) and IV (52middot0 ) had high Na content per 100 g or100ml (Fig 1)

Na content v first appearance of salt on ingredients listFigure 2 presents the analysis of Na content in the nutri-tional information (classified according to the UK FoodStandards Agency(39)) and the position in which saltappears in the studied productsrsquo ingredients lists

Regarding the position in which salt first appears on theingredients list of the 1208 products analysed 37middot1 (95 CI 32middot6 41middot7 ) listed salt between the first andthird positions There was no difference in this percentagewhen compared among products of low medium or highNa content (P= 0middot08) Other cut-off points for the positionof salt were used but the percentages among the three Nacontent categories remained similar in all cases

Na content by food product group and subgroupBased on Na information we defined median Na content byfood group and subgroup the P2ndashP98 for each subgroup aswell as the relationship between these percentiles (Table 1)

A large variation in Na content within different sub-groups was found In almost half of the subgroups (44 )the highest-Na product had an Na concentration at leastten times higher than the product with the lowest Na andin about 17 of the subgroups analysed the differenceswere even more extreme (about fifty times higher or more)This wide variation occurred in subgroups classified ashigh medium and low in Na

Ingredients list

Food products with added NaOn the ingredients lists fourteen different nomenclatures forsalt were found salt sodium chloride refined salt refinediodized salt iodized salt marine salt sea salt reduced-sodium salt hyposodic salt coarse salt special coarse saltiodized coarse salt cured salt and low salt Of the 1543citations found salt was the most common (86middot3 95 CI84middot3 88middot1) In 347 citations salt composed part of twenty-seven different types of compound ingredients includingsauces condimentsseasonings pasta cheeses cheese-based preparations meats meat-based products fillingbread flour pepper-based preparations flavour enhancersantioxidants brine and artificial colouring

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HealthNutrition

Sodium in processed foods sold in Brazil 3

Of all products analysed 14middot7 (95 CI 10middot4 20middot5 )had at least one compound ingredient recognized forcontaining salt in its composition (cheeses condimentsprepared broths seasonings in flavoured powders saucesand others) without describing the composition of theseingredients separately The presence of compound ingre-dients with this characteristic was also observed in 81middot2 (95 CI 71middot5 90middot7 ) of the sixty-nine studied products(4middot9 ) for which no citation of salt or Na-containing foodadditive was found on the ingredients list

Food additives containing NaSimilarly we studied Na-containing food additives citedon the ingredients lists (Table 2)

We found thirty-four different types of Na-containingfood additives resulting in 1764 citations on the

ingredients lists of the products analysed Of these 52middot0 (95 CI 48middot2 55middot6 ) contained at least one type ofNa-containing food additive and the maximum numberof Na-containing additives per product was eight (n 2)Sodium caseinate and emulsifying salts were consideredadditives despite their absence from the InternationalNumbering System because they are additive mixturesFourteen products (1middot0 ) had incomplete food additivedescriptions precluding the inclusion of these data in thetotal accounting of food additive citations

Discussion

The present study analysed Na labelling on processedand ultra-processed pre-prepared meals and prepared

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HealthNutrition

90

100

80

70

60

50

40

30

20

10

0

708 (n 34)

292 (n 14)

660 (n 301)

340 (n 155)

604 (n 425)

396 (n 279)

Low (le120 mg Na100 g or 100 ml)

Medium(gt120 and le600 mg Na100 g or 100 ml)

High(gt600 mg Na100 g or 100 ml)

Fig 2 Association between the first appearance of salt on the ingredients list ( first to third position fourth position or more)and the sodium content of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazil used inlunch or dinner according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1208) Excluded products includedcomplete seasonings and those prepared for broth products belonging to the broth concentrate and soup powder subgroup

100

90

80

70

60

50

40

30

20

10

0

n 14

n 53

n 123 n 144

n 22

n 55

n 15

n 0 n 0

n 15

n 89

n 67

n 46

n 119

n 5 n 2n 0

n 125

n 171

n 27

n 319

Group I Group II Group III Group IV Group V Group VI Group VIII

Fig 1 Classification of groups of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazilused in lunch or dinner by sodium content ( low (le120mg100 g or 100 ml) medium (gt120 and le 600 mg100 g or 100ml) high (gt600mg100 g or 100ml)) according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1411) Values are

percentages with their 95 confidence intervals represented by vertical bars Group I=Bread products cereals legumes rootstubers and their derivatives Group II=Fresh and canned vegetables Group III=Fruits juices nectars and fruit drinks GroupIV=Milk and derivatives Group V=Meat and eggs Group VI=Oils fats and seeds Group VIII=Sauces ready-made seasoningsbroths soups and prepared dishes No product analysed in the study was part of Group VII of the Brazilian nutrition labellinglegislation to describe serving sizes for packaged foods(22) so this group is not reported in the analyses

4 CA Martins et al

ingredients marketed in Brazil used in lunch or dinnerApproximately 60 of the products analysed had high Nacontent (gt600 mg100 g) and this high content occurred inpractically all food product groups especially those ingroup VIII complete seasonings (18 700mg Na100 g)broths and soup powders (4500 mg Na100 g) and powdersfor sauce preparation (4442mg Na100 g)

Studies conducted in other countries have also foundhigh Na content in processed food products In Canada17 of the 364 products with Na information analysedhad high Na content(40) In the UK the highest meanNa content was found in broths and sauces (1090 mg100 g)(30) In Australia the mean Na content of broths was6108 mg100 g(29) Another Australian study(41) observed

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HealthNutrition

Table 1 Sodium content (mg100 g or 100 ml) and sodium content classification by group and subgroup of processed and ultra-processedpre-prepared meals and prepared ingredients food products marketed in Brazil used in lunch or dinner (n 1411)

Food product groups and subgroups n MediandaggerNa content

classificationDaggerPercentiles(P2ndashP98)dagger

P98P2ratiodagger

I ndash Bread products cereals legumes roots tubers and their derivatives 190 860 HighInstant pasta with or without seasoning 78 1632 High 288ndash2566 8middot9Dehydrated pasta with filling 3 590 Medium 530ndash780 1middot5Fresh pasta with and without filling 50 581 Medium 43ndash1099 25middot6Ready-made mixtures for ricerisotto preparation 12 44 Low 0ndash2170sect 434middot0Ready-made mixtures for flavoured polenta preparation 5 1544 High 1530ndash1704 1middot1Soya-based breaded steak meatball and hamburger preparations 10 587 Medium 506ndash1000 2middot0Ready-to-consume manioc flour 13 591 Medium 337ndash923 2middot7Frozen filled cheese bread 1 665 HighFrozen cheese bread without filling 6 527 Medium 302ndash774 2middot6Tofu 3 320 Medium 150ndash323 2middot2Frozen pre-fried potatoes and cassava 9 335 Medium 24ndash451 18middot8

II ndash Fresh and canned vegetables 221 425 MediumTriple vegetable concentrate (extract) 27 403 Medium 302ndash733 2middot4Vegetable pureacutee or pulp including tomato 6 68 Low 0ndash260 52middot0Tomato sauce or sauces with bases of tomatoes and other vegetables 77 472 Medium 0ndash1530sect 306middot0Pickles and capers 8 2167 High 713ndash3110 4middot4Dehydrated vegetable preserves (dried tomatoes) 3 1615 High 355ndash2223 6middot3Pickled vegetables (artichokes asparagus mushrooms peppers cucumberand palm hearts) in brine vinegar and oil

56 424 Medium 140ndash1476 10middot5

Garnishes and other canned vegetables and fruits (carrots peas cornpeeled tomatoes and others)

62 371 Medium 0ndash3170 634middot0

III ndash Fruits juices nectars and fruit drinks 15 0 LowFruit preserves including fruit salad 15 0 Low 0ndash30sect 6middot0

IV ndash Milk and derivatives 171 633 HighGrated cheese 26 707 High 50ndash1660 33middot2Minas cheese 18 319 Medium 133ndash1833 13middot8Other cheeses (ricotta semi-hard white cream cheese melted andpaste)

127 637 High 50ndash1800 36middot0

V ndash Meats and eggs 170 877 HighMeat preparations with flour or breading 32 650 High 149ndash932 6middot3Meat preparations ndash seasoned smoked and cooked or pre-cooked 18 767 High 100ndash1483 14middot8Sausages ham and cold ham 35 1700 High 885ndash3638 4middot1Sausages all kinds 50 1067 High 370ndash1575 4middot3Kani-kama 3 718 High 615ndash885 1middot4Tuna sardines fish shellfish other fish pickled with or without sauces 28 317 Medium 152ndash1020 6middot7Pickled eggs 4 56 Low 56ndash56 1middot0

VI ndash Oils fats and seeds 127 1550 HighOlives 62 1650 High 820ndash2400 2middot9Mayonnaise and mayonnaise-based sauces 35 1050 High 708ndash1233 1middot7Oil-based salad dressings (all kinds) 30 1119 High 383ndash6000 15middot7

VIII ndash Sauces ready-to-consume seasonings broths soups and prepareddishes

522 873 High

Concentrated broths (meat chicken vegetable and others) and souppowders

95 4500 High 2384ndash23726 10middot0

Ketchup and mustard 41 717 High 0ndash2975sect 595middot0Soya- or vinegar-based sauces 67 2836 High 100ndash5490 54middot9Sauces based on dairy or broth products 30 544 Medium 50ndash3556 71middot1Powders to prepare sauces 8 4442 High 3903ndash4978 1middot3Miso soup 2 4585 High 4530ndash4640 1middot0Missoshiru 2 6980 High 6910ndash7050 1middot0Prepared and semi-prepared dishes not included in other table items 208 475 Medium 54ndash1170 21middot7Complete seasonings 69 18 700 High 2620ndash40300 15middot4

Food product groups and subgroups according to RDC no 3592003(22)daggerNa in mg100 g or mg100mlDaggerMedian Na content classified according to the Traffic Light Labels of the Food Standards Agency UK(39)sectTo facilitate calculation in the cases in which the minimum value is zero the minimum value was considered= 5mg Na100 g according to RDC no 3602003(23)

Sodium in processed foods sold in Brazil 5

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

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HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

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HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

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HealthNutrition

8 CA Martins et al

In Brazil nutrition labelling on packaged foods anddrinks (including information about Na) has been man-datory since 2001(21) This information must be describedin milligrams per serving with the percentage daily value(DV) calculated according to an average of 2400 mg NadValues less than 5 mg Na100 g food are consideredinsignificant amounts ie lsquozero sodiumrsquo

(2223) It is alsomandatory to present a list of ingredients in descendingorder according to the proportions used and food addi-tives must be described directly after the foods(24) Thusthe Brazilian Dietary Guidelines recommend checking theposition of salt in the ingredients list on processed foods toinform about salt content(25) since the product couldpotentially have a high concentration of this substancewhen it appears as one of the first ingredients(25ndash27)

Although labelling is an important tool for reducing thepopulationrsquos Na intake(1828) it has hardly been exploredscientifically in Brazil The high Na content and highvariability among similar products sold in supermarketshas long been recognized(82930) Knowing these contents(and their variations) is important for defining public policyas exemplified by successful initiatives for reformulationaimed at reducing the Na content in food productsmarketed in several countries(18283132) However there iscurrently no good scientific evidence on the Na content(and its variation) in processed foods marketed in BrazilGiven that pre-prepared meals and prepared ingredientscontribute to increased Na intake by the population(1128ndash30)

and that an increase in the purchase of these products bythe Brazilian population has been observed(101216) thepresent study analysed the labelling and Na content ofprocessed and ultra-processed pre-prepared meals andprepared ingredients marketed in Brazil and used in mainmeals specifically lunch or dinner

Methods

Data collectionThe present study was cross-sectional in design andevaluated Na labelling of processed food products sold ina supermarket in the city of Florianopolis southern BrazilThe supermarket was chosen intentionally and belongs toone of the ten largest supermarket chains in Brazil(33) withtwenty-six stores in the southern region of Brazil six ofwhich are located in Florianopolis The products sold inthis store are similar to those sold in other large super-market chains throughout the country The data werecollected from October to December 2011 The super-market manager authorized the research

Collection of label information was carried out with apre-tested instrument for the following analysis variables(i) product identification (ii) ingredients list (appearanceand position of salt on the list compound ingredients andNa-containing food additives appearing on the list) and(iii) Na information (Na in the nutritional information serving

size in grams and Na content in milligrams per serving)For the purpose of the study a compound ingredientwas defined as any ingredient included on the list that iscomposed of two or more ingredients(24) Food additivescontaining Na were identified using the specific Brazilianresolution for food additives(34) and Mercosulrsquos HarmonizedGeneral List of Food Additives and Their FunctionalClasses(35)

The data collection team received training and partici-pated in the instrumentrsquos pilot test For quality controlinformation on two key questions (Na content in milligramsper serving and position of first appearance of salt on theingredients list) was collected twice for 3middot2 of the foodsanalysed (n 44) According to the BlandndashAltman test thedifference in means for the variable lsquoNa content in milligramsper servingrsquowas 0middot05 mg (interval of plusmn 2 SD of minus0middot5 and 0middot6)while the κ value for the variable lsquoposition of the firstappearance of salt on the ingredients listrsquo was 1middot00

Inclusion criteria for food products in the studyThe study included all those food products covered underBrazilian nutrition labelling legislation(23) which have thefollowing characteristics (i) appearance of Na on theingredients list (ii) classified as processed or ultra-processedfood products (iii) pre-prepared meal or prepared ingre-dients and (iv) habitually used by the Brazilian populationin lunch and dinner meals(5141536ndash38)

To assess the true variability in Na content for each typeof specific product products that did not include Na amongtheir ingredients were only included in the sample whenother products with similar characteristics contained thisingredient Information on the packaging of identical pro-ducts of different sizes was recorded separately becausetheir ingredients lists also differed Products habitually usedby the Brazilian population in lunch and dinner meals weredefined based on Brazilian literature(5141536ndash38) Breadwas not included in the analyses as Brazilians do notcustomarily eat these products in the meals studied Wealso excluded products that were fractionated labelled andmarketed by the supermarket itself since such products arenot required to be labelled in Brazil(23)

Statistical treatment and analysis of dataThe collected data were entered into two separatedatabases and later checked for errors and validated inEpiDatareg 3middot1 (EpiData Association Odense Denmark)The products were distributed into seven groups andforty-one subgroups predefined by Brazilian nutritionlabelling legislation to describe serving sizes for packagedfoods(22) Since no product analysed in the present studywas part of Group VII of this legislation (Group VII Sugarand products that provide energy from carbohydrates andfats) this group is not reported in the analyses A quantityequivalence of Na in milligrams per 100 g or 100ml offood was determined for all the products based on servingsize information Na content in milligrams per 100 g

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HealthNutrition

2 CA Martins et al

or 100 ml of food was classified as high content (gt600 mgNa) medium content (gt120 and le 600 mg Na) and lowcontent (le120mg Na) according to the Traffic Light Labelsof the UK Food Standards Agency(39) The first appearanceof salt on the ingredients list was treated as a dichotomousvariable (first to third position fourth position or more)

We conducted a descriptive statistical analysis pre-senting absolute and relative frequency median Nacontent percentiles and relationships between subgrouppercentiles Data dispersion was presented in the 2nd and98th percentiles (P2ndashP98) due to the asymmetry of thevariable lsquoNa content in milligrams per 100 g or 100ml offoodrsquo and to have an overview of information variabilitywithout having the products with extreme values (n 55)influence the results This interval therefore represents thedispersion of 96 of the food products The ratio betweenthe 98th and 2nd percentiles was assessed based on thesevalues with the aim of establishing the differences in Nacontent between similar products In order to facilitatecalculation of the P98P2 ratio for products containing0mg Na100 g the value of 5 mg Na100 g was usedwhich is an amount defined as insignificant by Braziliannutrition labelling legislation(23)

A χ2 test was used to assess the association betweenproduct Na content and the first appearance of salt on theingredients list Due to infeasibility for inclusion in thisanalysis the following products were excluded from thisanalysis (i) those that included salt as their main ingre-dient (complete seasonings and those prepared for brothn 103) since none of these products would be consumeddirectly affecting interpretation of the data (ii) those thatdid not include salt on the ingredients list (n 100) and(iii) those that did not have Na information on the nutritionlabel (n 5)

The statistical software package Statareg version 11middot0 wasused for the statistical analyses with Plt 0middot05 consideredindicative of statistical significance

Results

Of the 4538 Na-containing processed food productsavailable for sale at the supermarket 1416 were classed asprocessed and ultra-processed pre-prepared meals andprepared ingredients used for lunch and dinner There-fore the present study analysed 1416 products by 211different manufacturers ndash 87middot6 of the products havingbeen produced in Brazil The other products were fromArgentina (n 35) Italy (n 27) Spain (n 24) Germany(n 22) the USA (n 21) Peru (n 10) Uruguay (n 7) Belgium(n 5) Chile (n 5) France (n 5) China (n 4) Mexico (n 4)Poland (n 3) Portugal (n 2) and Ecuador (n 1)

Nutritional informationOf the products analysed five (0middot4 ) did not include Nainformation on the nutrition label The remaining 1411

products were distributed into seven groups and forty-onesubgroups

Classification of Na content (mg100 g or 100ml)according to the UK Food Standards AgencyOf all the products with Na nutrition information (n 1411)58middot8 (95 CI 55middot4 62middot2 ) were classified as having ahigh Na content (gt600mg100 g or 100ml) and 7middot0 (95 CI 2middot9 14middot2 ) were classified as having low Nacontent (le120 mg100 g or 100ml)(39) In the Na contentclassification by food group the majority of productsincluded in groups VI (98middot4 ) V (70middot0 ) I (64middot7 ) VIII(61middot7 ) and IV (52middot0 ) had high Na content per 100 g or100ml (Fig 1)

Na content v first appearance of salt on ingredients listFigure 2 presents the analysis of Na content in the nutri-tional information (classified according to the UK FoodStandards Agency(39)) and the position in which saltappears in the studied productsrsquo ingredients lists

Regarding the position in which salt first appears on theingredients list of the 1208 products analysed 37middot1 (95 CI 32middot6 41middot7 ) listed salt between the first andthird positions There was no difference in this percentagewhen compared among products of low medium or highNa content (P= 0middot08) Other cut-off points for the positionof salt were used but the percentages among the three Nacontent categories remained similar in all cases

Na content by food product group and subgroupBased on Na information we defined median Na content byfood group and subgroup the P2ndashP98 for each subgroup aswell as the relationship between these percentiles (Table 1)

A large variation in Na content within different sub-groups was found In almost half of the subgroups (44 )the highest-Na product had an Na concentration at leastten times higher than the product with the lowest Na andin about 17 of the subgroups analysed the differenceswere even more extreme (about fifty times higher or more)This wide variation occurred in subgroups classified ashigh medium and low in Na

Ingredients list

Food products with added NaOn the ingredients lists fourteen different nomenclatures forsalt were found salt sodium chloride refined salt refinediodized salt iodized salt marine salt sea salt reduced-sodium salt hyposodic salt coarse salt special coarse saltiodized coarse salt cured salt and low salt Of the 1543citations found salt was the most common (86middot3 95 CI84middot3 88middot1) In 347 citations salt composed part of twenty-seven different types of compound ingredients includingsauces condimentsseasonings pasta cheeses cheese-based preparations meats meat-based products fillingbread flour pepper-based preparations flavour enhancersantioxidants brine and artificial colouring

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HealthNutrition

Sodium in processed foods sold in Brazil 3

Of all products analysed 14middot7 (95 CI 10middot4 20middot5 )had at least one compound ingredient recognized forcontaining salt in its composition (cheeses condimentsprepared broths seasonings in flavoured powders saucesand others) without describing the composition of theseingredients separately The presence of compound ingre-dients with this characteristic was also observed in 81middot2 (95 CI 71middot5 90middot7 ) of the sixty-nine studied products(4middot9 ) for which no citation of salt or Na-containing foodadditive was found on the ingredients list

Food additives containing NaSimilarly we studied Na-containing food additives citedon the ingredients lists (Table 2)

We found thirty-four different types of Na-containingfood additives resulting in 1764 citations on the

ingredients lists of the products analysed Of these 52middot0 (95 CI 48middot2 55middot6 ) contained at least one type ofNa-containing food additive and the maximum numberof Na-containing additives per product was eight (n 2)Sodium caseinate and emulsifying salts were consideredadditives despite their absence from the InternationalNumbering System because they are additive mixturesFourteen products (1middot0 ) had incomplete food additivedescriptions precluding the inclusion of these data in thetotal accounting of food additive citations

Discussion

The present study analysed Na labelling on processedand ultra-processed pre-prepared meals and prepared

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HealthNutrition

90

100

80

70

60

50

40

30

20

10

0

708 (n 34)

292 (n 14)

660 (n 301)

340 (n 155)

604 (n 425)

396 (n 279)

Low (le120 mg Na100 g or 100 ml)

Medium(gt120 and le600 mg Na100 g or 100 ml)

High(gt600 mg Na100 g or 100 ml)

Fig 2 Association between the first appearance of salt on the ingredients list ( first to third position fourth position or more)and the sodium content of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazil used inlunch or dinner according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1208) Excluded products includedcomplete seasonings and those prepared for broth products belonging to the broth concentrate and soup powder subgroup

100

90

80

70

60

50

40

30

20

10

0

n 14

n 53

n 123 n 144

n 22

n 55

n 15

n 0 n 0

n 15

n 89

n 67

n 46

n 119

n 5 n 2n 0

n 125

n 171

n 27

n 319

Group I Group II Group III Group IV Group V Group VI Group VIII

Fig 1 Classification of groups of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazilused in lunch or dinner by sodium content ( low (le120mg100 g or 100 ml) medium (gt120 and le 600 mg100 g or 100ml) high (gt600mg100 g or 100ml)) according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1411) Values are

percentages with their 95 confidence intervals represented by vertical bars Group I=Bread products cereals legumes rootstubers and their derivatives Group II=Fresh and canned vegetables Group III=Fruits juices nectars and fruit drinks GroupIV=Milk and derivatives Group V=Meat and eggs Group VI=Oils fats and seeds Group VIII=Sauces ready-made seasoningsbroths soups and prepared dishes No product analysed in the study was part of Group VII of the Brazilian nutrition labellinglegislation to describe serving sizes for packaged foods(22) so this group is not reported in the analyses

4 CA Martins et al

ingredients marketed in Brazil used in lunch or dinnerApproximately 60 of the products analysed had high Nacontent (gt600 mg100 g) and this high content occurred inpractically all food product groups especially those ingroup VIII complete seasonings (18 700mg Na100 g)broths and soup powders (4500 mg Na100 g) and powdersfor sauce preparation (4442mg Na100 g)

Studies conducted in other countries have also foundhigh Na content in processed food products In Canada17 of the 364 products with Na information analysedhad high Na content(40) In the UK the highest meanNa content was found in broths and sauces (1090 mg100 g)(30) In Australia the mean Na content of broths was6108 mg100 g(29) Another Australian study(41) observed

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HealthNutrition

Table 1 Sodium content (mg100 g or 100 ml) and sodium content classification by group and subgroup of processed and ultra-processedpre-prepared meals and prepared ingredients food products marketed in Brazil used in lunch or dinner (n 1411)

Food product groups and subgroups n MediandaggerNa content

classificationDaggerPercentiles(P2ndashP98)dagger

P98P2ratiodagger

I ndash Bread products cereals legumes roots tubers and their derivatives 190 860 HighInstant pasta with or without seasoning 78 1632 High 288ndash2566 8middot9Dehydrated pasta with filling 3 590 Medium 530ndash780 1middot5Fresh pasta with and without filling 50 581 Medium 43ndash1099 25middot6Ready-made mixtures for ricerisotto preparation 12 44 Low 0ndash2170sect 434middot0Ready-made mixtures for flavoured polenta preparation 5 1544 High 1530ndash1704 1middot1Soya-based breaded steak meatball and hamburger preparations 10 587 Medium 506ndash1000 2middot0Ready-to-consume manioc flour 13 591 Medium 337ndash923 2middot7Frozen filled cheese bread 1 665 HighFrozen cheese bread without filling 6 527 Medium 302ndash774 2middot6Tofu 3 320 Medium 150ndash323 2middot2Frozen pre-fried potatoes and cassava 9 335 Medium 24ndash451 18middot8

II ndash Fresh and canned vegetables 221 425 MediumTriple vegetable concentrate (extract) 27 403 Medium 302ndash733 2middot4Vegetable pureacutee or pulp including tomato 6 68 Low 0ndash260 52middot0Tomato sauce or sauces with bases of tomatoes and other vegetables 77 472 Medium 0ndash1530sect 306middot0Pickles and capers 8 2167 High 713ndash3110 4middot4Dehydrated vegetable preserves (dried tomatoes) 3 1615 High 355ndash2223 6middot3Pickled vegetables (artichokes asparagus mushrooms peppers cucumberand palm hearts) in brine vinegar and oil

56 424 Medium 140ndash1476 10middot5

Garnishes and other canned vegetables and fruits (carrots peas cornpeeled tomatoes and others)

62 371 Medium 0ndash3170 634middot0

III ndash Fruits juices nectars and fruit drinks 15 0 LowFruit preserves including fruit salad 15 0 Low 0ndash30sect 6middot0

IV ndash Milk and derivatives 171 633 HighGrated cheese 26 707 High 50ndash1660 33middot2Minas cheese 18 319 Medium 133ndash1833 13middot8Other cheeses (ricotta semi-hard white cream cheese melted andpaste)

127 637 High 50ndash1800 36middot0

V ndash Meats and eggs 170 877 HighMeat preparations with flour or breading 32 650 High 149ndash932 6middot3Meat preparations ndash seasoned smoked and cooked or pre-cooked 18 767 High 100ndash1483 14middot8Sausages ham and cold ham 35 1700 High 885ndash3638 4middot1Sausages all kinds 50 1067 High 370ndash1575 4middot3Kani-kama 3 718 High 615ndash885 1middot4Tuna sardines fish shellfish other fish pickled with or without sauces 28 317 Medium 152ndash1020 6middot7Pickled eggs 4 56 Low 56ndash56 1middot0

VI ndash Oils fats and seeds 127 1550 HighOlives 62 1650 High 820ndash2400 2middot9Mayonnaise and mayonnaise-based sauces 35 1050 High 708ndash1233 1middot7Oil-based salad dressings (all kinds) 30 1119 High 383ndash6000 15middot7

VIII ndash Sauces ready-to-consume seasonings broths soups and prepareddishes

522 873 High

Concentrated broths (meat chicken vegetable and others) and souppowders

95 4500 High 2384ndash23726 10middot0

Ketchup and mustard 41 717 High 0ndash2975sect 595middot0Soya- or vinegar-based sauces 67 2836 High 100ndash5490 54middot9Sauces based on dairy or broth products 30 544 Medium 50ndash3556 71middot1Powders to prepare sauces 8 4442 High 3903ndash4978 1middot3Miso soup 2 4585 High 4530ndash4640 1middot0Missoshiru 2 6980 High 6910ndash7050 1middot0Prepared and semi-prepared dishes not included in other table items 208 475 Medium 54ndash1170 21middot7Complete seasonings 69 18 700 High 2620ndash40300 15middot4

Food product groups and subgroups according to RDC no 3592003(22)daggerNa in mg100 g or mg100mlDaggerMedian Na content classified according to the Traffic Light Labels of the Food Standards Agency UK(39)sectTo facilitate calculation in the cases in which the minimum value is zero the minimum value was considered= 5mg Na100 g according to RDC no 3602003(23)

Sodium in processed foods sold in Brazil 5

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

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HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

or 100 ml of food was classified as high content (gt600 mgNa) medium content (gt120 and le 600 mg Na) and lowcontent (le120mg Na) according to the Traffic Light Labelsof the UK Food Standards Agency(39) The first appearanceof salt on the ingredients list was treated as a dichotomousvariable (first to third position fourth position or more)

We conducted a descriptive statistical analysis pre-senting absolute and relative frequency median Nacontent percentiles and relationships between subgrouppercentiles Data dispersion was presented in the 2nd and98th percentiles (P2ndashP98) due to the asymmetry of thevariable lsquoNa content in milligrams per 100 g or 100ml offoodrsquo and to have an overview of information variabilitywithout having the products with extreme values (n 55)influence the results This interval therefore represents thedispersion of 96 of the food products The ratio betweenthe 98th and 2nd percentiles was assessed based on thesevalues with the aim of establishing the differences in Nacontent between similar products In order to facilitatecalculation of the P98P2 ratio for products containing0mg Na100 g the value of 5 mg Na100 g was usedwhich is an amount defined as insignificant by Braziliannutrition labelling legislation(23)

A χ2 test was used to assess the association betweenproduct Na content and the first appearance of salt on theingredients list Due to infeasibility for inclusion in thisanalysis the following products were excluded from thisanalysis (i) those that included salt as their main ingre-dient (complete seasonings and those prepared for brothn 103) since none of these products would be consumeddirectly affecting interpretation of the data (ii) those thatdid not include salt on the ingredients list (n 100) and(iii) those that did not have Na information on the nutritionlabel (n 5)

The statistical software package Statareg version 11middot0 wasused for the statistical analyses with Plt 0middot05 consideredindicative of statistical significance

Results

Of the 4538 Na-containing processed food productsavailable for sale at the supermarket 1416 were classed asprocessed and ultra-processed pre-prepared meals andprepared ingredients used for lunch and dinner There-fore the present study analysed 1416 products by 211different manufacturers ndash 87middot6 of the products havingbeen produced in Brazil The other products were fromArgentina (n 35) Italy (n 27) Spain (n 24) Germany(n 22) the USA (n 21) Peru (n 10) Uruguay (n 7) Belgium(n 5) Chile (n 5) France (n 5) China (n 4) Mexico (n 4)Poland (n 3) Portugal (n 2) and Ecuador (n 1)

Nutritional informationOf the products analysed five (0middot4 ) did not include Nainformation on the nutrition label The remaining 1411

products were distributed into seven groups and forty-onesubgroups

Classification of Na content (mg100 g or 100ml)according to the UK Food Standards AgencyOf all the products with Na nutrition information (n 1411)58middot8 (95 CI 55middot4 62middot2 ) were classified as having ahigh Na content (gt600mg100 g or 100ml) and 7middot0 (95 CI 2middot9 14middot2 ) were classified as having low Nacontent (le120 mg100 g or 100ml)(39) In the Na contentclassification by food group the majority of productsincluded in groups VI (98middot4 ) V (70middot0 ) I (64middot7 ) VIII(61middot7 ) and IV (52middot0 ) had high Na content per 100 g or100ml (Fig 1)

Na content v first appearance of salt on ingredients listFigure 2 presents the analysis of Na content in the nutri-tional information (classified according to the UK FoodStandards Agency(39)) and the position in which saltappears in the studied productsrsquo ingredients lists

Regarding the position in which salt first appears on theingredients list of the 1208 products analysed 37middot1 (95 CI 32middot6 41middot7 ) listed salt between the first andthird positions There was no difference in this percentagewhen compared among products of low medium or highNa content (P= 0middot08) Other cut-off points for the positionof salt were used but the percentages among the three Nacontent categories remained similar in all cases

Na content by food product group and subgroupBased on Na information we defined median Na content byfood group and subgroup the P2ndashP98 for each subgroup aswell as the relationship between these percentiles (Table 1)

A large variation in Na content within different sub-groups was found In almost half of the subgroups (44 )the highest-Na product had an Na concentration at leastten times higher than the product with the lowest Na andin about 17 of the subgroups analysed the differenceswere even more extreme (about fifty times higher or more)This wide variation occurred in subgroups classified ashigh medium and low in Na

Ingredients list

Food products with added NaOn the ingredients lists fourteen different nomenclatures forsalt were found salt sodium chloride refined salt refinediodized salt iodized salt marine salt sea salt reduced-sodium salt hyposodic salt coarse salt special coarse saltiodized coarse salt cured salt and low salt Of the 1543citations found salt was the most common (86middot3 95 CI84middot3 88middot1) In 347 citations salt composed part of twenty-seven different types of compound ingredients includingsauces condimentsseasonings pasta cheeses cheese-based preparations meats meat-based products fillingbread flour pepper-based preparations flavour enhancersantioxidants brine and artificial colouring

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HealthNutrition

Sodium in processed foods sold in Brazil 3

Of all products analysed 14middot7 (95 CI 10middot4 20middot5 )had at least one compound ingredient recognized forcontaining salt in its composition (cheeses condimentsprepared broths seasonings in flavoured powders saucesand others) without describing the composition of theseingredients separately The presence of compound ingre-dients with this characteristic was also observed in 81middot2 (95 CI 71middot5 90middot7 ) of the sixty-nine studied products(4middot9 ) for which no citation of salt or Na-containing foodadditive was found on the ingredients list

Food additives containing NaSimilarly we studied Na-containing food additives citedon the ingredients lists (Table 2)

We found thirty-four different types of Na-containingfood additives resulting in 1764 citations on the

ingredients lists of the products analysed Of these 52middot0 (95 CI 48middot2 55middot6 ) contained at least one type ofNa-containing food additive and the maximum numberof Na-containing additives per product was eight (n 2)Sodium caseinate and emulsifying salts were consideredadditives despite their absence from the InternationalNumbering System because they are additive mixturesFourteen products (1middot0 ) had incomplete food additivedescriptions precluding the inclusion of these data in thetotal accounting of food additive citations

Discussion

The present study analysed Na labelling on processedand ultra-processed pre-prepared meals and prepared

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HealthNutrition

90

100

80

70

60

50

40

30

20

10

0

708 (n 34)

292 (n 14)

660 (n 301)

340 (n 155)

604 (n 425)

396 (n 279)

Low (le120 mg Na100 g or 100 ml)

Medium(gt120 and le600 mg Na100 g or 100 ml)

High(gt600 mg Na100 g or 100 ml)

Fig 2 Association between the first appearance of salt on the ingredients list ( first to third position fourth position or more)and the sodium content of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazil used inlunch or dinner according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1208) Excluded products includedcomplete seasonings and those prepared for broth products belonging to the broth concentrate and soup powder subgroup

100

90

80

70

60

50

40

30

20

10

0

n 14

n 53

n 123 n 144

n 22

n 55

n 15

n 0 n 0

n 15

n 89

n 67

n 46

n 119

n 5 n 2n 0

n 125

n 171

n 27

n 319

Group I Group II Group III Group IV Group V Group VI Group VIII

Fig 1 Classification of groups of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazilused in lunch or dinner by sodium content ( low (le120mg100 g or 100 ml) medium (gt120 and le 600 mg100 g or 100ml) high (gt600mg100 g or 100ml)) according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1411) Values are

percentages with their 95 confidence intervals represented by vertical bars Group I=Bread products cereals legumes rootstubers and their derivatives Group II=Fresh and canned vegetables Group III=Fruits juices nectars and fruit drinks GroupIV=Milk and derivatives Group V=Meat and eggs Group VI=Oils fats and seeds Group VIII=Sauces ready-made seasoningsbroths soups and prepared dishes No product analysed in the study was part of Group VII of the Brazilian nutrition labellinglegislation to describe serving sizes for packaged foods(22) so this group is not reported in the analyses

4 CA Martins et al

ingredients marketed in Brazil used in lunch or dinnerApproximately 60 of the products analysed had high Nacontent (gt600 mg100 g) and this high content occurred inpractically all food product groups especially those ingroup VIII complete seasonings (18 700mg Na100 g)broths and soup powders (4500 mg Na100 g) and powdersfor sauce preparation (4442mg Na100 g)

Studies conducted in other countries have also foundhigh Na content in processed food products In Canada17 of the 364 products with Na information analysedhad high Na content(40) In the UK the highest meanNa content was found in broths and sauces (1090 mg100 g)(30) In Australia the mean Na content of broths was6108 mg100 g(29) Another Australian study(41) observed

Public

HealthNutrition

Table 1 Sodium content (mg100 g or 100 ml) and sodium content classification by group and subgroup of processed and ultra-processedpre-prepared meals and prepared ingredients food products marketed in Brazil used in lunch or dinner (n 1411)

Food product groups and subgroups n MediandaggerNa content

classificationDaggerPercentiles(P2ndashP98)dagger

P98P2ratiodagger

I ndash Bread products cereals legumes roots tubers and their derivatives 190 860 HighInstant pasta with or without seasoning 78 1632 High 288ndash2566 8middot9Dehydrated pasta with filling 3 590 Medium 530ndash780 1middot5Fresh pasta with and without filling 50 581 Medium 43ndash1099 25middot6Ready-made mixtures for ricerisotto preparation 12 44 Low 0ndash2170sect 434middot0Ready-made mixtures for flavoured polenta preparation 5 1544 High 1530ndash1704 1middot1Soya-based breaded steak meatball and hamburger preparations 10 587 Medium 506ndash1000 2middot0Ready-to-consume manioc flour 13 591 Medium 337ndash923 2middot7Frozen filled cheese bread 1 665 HighFrozen cheese bread without filling 6 527 Medium 302ndash774 2middot6Tofu 3 320 Medium 150ndash323 2middot2Frozen pre-fried potatoes and cassava 9 335 Medium 24ndash451 18middot8

II ndash Fresh and canned vegetables 221 425 MediumTriple vegetable concentrate (extract) 27 403 Medium 302ndash733 2middot4Vegetable pureacutee or pulp including tomato 6 68 Low 0ndash260 52middot0Tomato sauce or sauces with bases of tomatoes and other vegetables 77 472 Medium 0ndash1530sect 306middot0Pickles and capers 8 2167 High 713ndash3110 4middot4Dehydrated vegetable preserves (dried tomatoes) 3 1615 High 355ndash2223 6middot3Pickled vegetables (artichokes asparagus mushrooms peppers cucumberand palm hearts) in brine vinegar and oil

56 424 Medium 140ndash1476 10middot5

Garnishes and other canned vegetables and fruits (carrots peas cornpeeled tomatoes and others)

62 371 Medium 0ndash3170 634middot0

III ndash Fruits juices nectars and fruit drinks 15 0 LowFruit preserves including fruit salad 15 0 Low 0ndash30sect 6middot0

IV ndash Milk and derivatives 171 633 HighGrated cheese 26 707 High 50ndash1660 33middot2Minas cheese 18 319 Medium 133ndash1833 13middot8Other cheeses (ricotta semi-hard white cream cheese melted andpaste)

127 637 High 50ndash1800 36middot0

V ndash Meats and eggs 170 877 HighMeat preparations with flour or breading 32 650 High 149ndash932 6middot3Meat preparations ndash seasoned smoked and cooked or pre-cooked 18 767 High 100ndash1483 14middot8Sausages ham and cold ham 35 1700 High 885ndash3638 4middot1Sausages all kinds 50 1067 High 370ndash1575 4middot3Kani-kama 3 718 High 615ndash885 1middot4Tuna sardines fish shellfish other fish pickled with or without sauces 28 317 Medium 152ndash1020 6middot7Pickled eggs 4 56 Low 56ndash56 1middot0

VI ndash Oils fats and seeds 127 1550 HighOlives 62 1650 High 820ndash2400 2middot9Mayonnaise and mayonnaise-based sauces 35 1050 High 708ndash1233 1middot7Oil-based salad dressings (all kinds) 30 1119 High 383ndash6000 15middot7

VIII ndash Sauces ready-to-consume seasonings broths soups and prepareddishes

522 873 High

Concentrated broths (meat chicken vegetable and others) and souppowders

95 4500 High 2384ndash23726 10middot0

Ketchup and mustard 41 717 High 0ndash2975sect 595middot0Soya- or vinegar-based sauces 67 2836 High 100ndash5490 54middot9Sauces based on dairy or broth products 30 544 Medium 50ndash3556 71middot1Powders to prepare sauces 8 4442 High 3903ndash4978 1middot3Miso soup 2 4585 High 4530ndash4640 1middot0Missoshiru 2 6980 High 6910ndash7050 1middot0Prepared and semi-prepared dishes not included in other table items 208 475 Medium 54ndash1170 21middot7Complete seasonings 69 18 700 High 2620ndash40300 15middot4

Food product groups and subgroups according to RDC no 3592003(22)daggerNa in mg100 g or mg100mlDaggerMedian Na content classified according to the Traffic Light Labels of the Food Standards Agency UK(39)sectTo facilitate calculation in the cases in which the minimum value is zero the minimum value was considered= 5mg Na100 g according to RDC no 3602003(23)

Sodium in processed foods sold in Brazil 5

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

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HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

Of all products analysed 14middot7 (95 CI 10middot4 20middot5 )had at least one compound ingredient recognized forcontaining salt in its composition (cheeses condimentsprepared broths seasonings in flavoured powders saucesand others) without describing the composition of theseingredients separately The presence of compound ingre-dients with this characteristic was also observed in 81middot2 (95 CI 71middot5 90middot7 ) of the sixty-nine studied products(4middot9 ) for which no citation of salt or Na-containing foodadditive was found on the ingredients list

Food additives containing NaSimilarly we studied Na-containing food additives citedon the ingredients lists (Table 2)

We found thirty-four different types of Na-containingfood additives resulting in 1764 citations on the

ingredients lists of the products analysed Of these 52middot0 (95 CI 48middot2 55middot6 ) contained at least one type ofNa-containing food additive and the maximum numberof Na-containing additives per product was eight (n 2)Sodium caseinate and emulsifying salts were consideredadditives despite their absence from the InternationalNumbering System because they are additive mixturesFourteen products (1middot0 ) had incomplete food additivedescriptions precluding the inclusion of these data in thetotal accounting of food additive citations

Discussion

The present study analysed Na labelling on processedand ultra-processed pre-prepared meals and prepared

Public

HealthNutrition

90

100

80

70

60

50

40

30

20

10

0

708 (n 34)

292 (n 14)

660 (n 301)

340 (n 155)

604 (n 425)

396 (n 279)

Low (le120 mg Na100 g or 100 ml)

Medium(gt120 and le600 mg Na100 g or 100 ml)

High(gt600 mg Na100 g or 100 ml)

Fig 2 Association between the first appearance of salt on the ingredients list ( first to third position fourth position or more)and the sodium content of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazil used inlunch or dinner according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1208) Excluded products includedcomplete seasonings and those prepared for broth products belonging to the broth concentrate and soup powder subgroup

100

90

80

70

60

50

40

30

20

10

0

n 14

n 53

n 123 n 144

n 22

n 55

n 15

n 0 n 0

n 15

n 89

n 67

n 46

n 119

n 5 n 2n 0

n 125

n 171

n 27

n 319

Group I Group II Group III Group IV Group V Group VI Group VIII

Fig 1 Classification of groups of processed and ultra-processed pre-prepared meals and prepared ingredients marketed in Brazilused in lunch or dinner by sodium content ( low (le120mg100 g or 100 ml) medium (gt120 and le 600 mg100 g or 100ml) high (gt600mg100 g or 100ml)) according to the Traffic Light Labels of the Food Standards Agency UK(39) (n 1411) Values are

percentages with their 95 confidence intervals represented by vertical bars Group I=Bread products cereals legumes rootstubers and their derivatives Group II=Fresh and canned vegetables Group III=Fruits juices nectars and fruit drinks GroupIV=Milk and derivatives Group V=Meat and eggs Group VI=Oils fats and seeds Group VIII=Sauces ready-made seasoningsbroths soups and prepared dishes No product analysed in the study was part of Group VII of the Brazilian nutrition labellinglegislation to describe serving sizes for packaged foods(22) so this group is not reported in the analyses

4 CA Martins et al

ingredients marketed in Brazil used in lunch or dinnerApproximately 60 of the products analysed had high Nacontent (gt600 mg100 g) and this high content occurred inpractically all food product groups especially those ingroup VIII complete seasonings (18 700mg Na100 g)broths and soup powders (4500 mg Na100 g) and powdersfor sauce preparation (4442mg Na100 g)

Studies conducted in other countries have also foundhigh Na content in processed food products In Canada17 of the 364 products with Na information analysedhad high Na content(40) In the UK the highest meanNa content was found in broths and sauces (1090 mg100 g)(30) In Australia the mean Na content of broths was6108 mg100 g(29) Another Australian study(41) observed

Public

HealthNutrition

Table 1 Sodium content (mg100 g or 100 ml) and sodium content classification by group and subgroup of processed and ultra-processedpre-prepared meals and prepared ingredients food products marketed in Brazil used in lunch or dinner (n 1411)

Food product groups and subgroups n MediandaggerNa content

classificationDaggerPercentiles(P2ndashP98)dagger

P98P2ratiodagger

I ndash Bread products cereals legumes roots tubers and their derivatives 190 860 HighInstant pasta with or without seasoning 78 1632 High 288ndash2566 8middot9Dehydrated pasta with filling 3 590 Medium 530ndash780 1middot5Fresh pasta with and without filling 50 581 Medium 43ndash1099 25middot6Ready-made mixtures for ricerisotto preparation 12 44 Low 0ndash2170sect 434middot0Ready-made mixtures for flavoured polenta preparation 5 1544 High 1530ndash1704 1middot1Soya-based breaded steak meatball and hamburger preparations 10 587 Medium 506ndash1000 2middot0Ready-to-consume manioc flour 13 591 Medium 337ndash923 2middot7Frozen filled cheese bread 1 665 HighFrozen cheese bread without filling 6 527 Medium 302ndash774 2middot6Tofu 3 320 Medium 150ndash323 2middot2Frozen pre-fried potatoes and cassava 9 335 Medium 24ndash451 18middot8

II ndash Fresh and canned vegetables 221 425 MediumTriple vegetable concentrate (extract) 27 403 Medium 302ndash733 2middot4Vegetable pureacutee or pulp including tomato 6 68 Low 0ndash260 52middot0Tomato sauce or sauces with bases of tomatoes and other vegetables 77 472 Medium 0ndash1530sect 306middot0Pickles and capers 8 2167 High 713ndash3110 4middot4Dehydrated vegetable preserves (dried tomatoes) 3 1615 High 355ndash2223 6middot3Pickled vegetables (artichokes asparagus mushrooms peppers cucumberand palm hearts) in brine vinegar and oil

56 424 Medium 140ndash1476 10middot5

Garnishes and other canned vegetables and fruits (carrots peas cornpeeled tomatoes and others)

62 371 Medium 0ndash3170 634middot0

III ndash Fruits juices nectars and fruit drinks 15 0 LowFruit preserves including fruit salad 15 0 Low 0ndash30sect 6middot0

IV ndash Milk and derivatives 171 633 HighGrated cheese 26 707 High 50ndash1660 33middot2Minas cheese 18 319 Medium 133ndash1833 13middot8Other cheeses (ricotta semi-hard white cream cheese melted andpaste)

127 637 High 50ndash1800 36middot0

V ndash Meats and eggs 170 877 HighMeat preparations with flour or breading 32 650 High 149ndash932 6middot3Meat preparations ndash seasoned smoked and cooked or pre-cooked 18 767 High 100ndash1483 14middot8Sausages ham and cold ham 35 1700 High 885ndash3638 4middot1Sausages all kinds 50 1067 High 370ndash1575 4middot3Kani-kama 3 718 High 615ndash885 1middot4Tuna sardines fish shellfish other fish pickled with or without sauces 28 317 Medium 152ndash1020 6middot7Pickled eggs 4 56 Low 56ndash56 1middot0

VI ndash Oils fats and seeds 127 1550 HighOlives 62 1650 High 820ndash2400 2middot9Mayonnaise and mayonnaise-based sauces 35 1050 High 708ndash1233 1middot7Oil-based salad dressings (all kinds) 30 1119 High 383ndash6000 15middot7

VIII ndash Sauces ready-to-consume seasonings broths soups and prepareddishes

522 873 High

Concentrated broths (meat chicken vegetable and others) and souppowders

95 4500 High 2384ndash23726 10middot0

Ketchup and mustard 41 717 High 0ndash2975sect 595middot0Soya- or vinegar-based sauces 67 2836 High 100ndash5490 54middot9Sauces based on dairy or broth products 30 544 Medium 50ndash3556 71middot1Powders to prepare sauces 8 4442 High 3903ndash4978 1middot3Miso soup 2 4585 High 4530ndash4640 1middot0Missoshiru 2 6980 High 6910ndash7050 1middot0Prepared and semi-prepared dishes not included in other table items 208 475 Medium 54ndash1170 21middot7Complete seasonings 69 18 700 High 2620ndash40300 15middot4

Food product groups and subgroups according to RDC no 3592003(22)daggerNa in mg100 g or mg100mlDaggerMedian Na content classified according to the Traffic Light Labels of the Food Standards Agency UK(39)sectTo facilitate calculation in the cases in which the minimum value is zero the minimum value was considered= 5mg Na100 g according to RDC no 3602003(23)

Sodium in processed foods sold in Brazil 5

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

Public

HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

ingredients marketed in Brazil used in lunch or dinnerApproximately 60 of the products analysed had high Nacontent (gt600 mg100 g) and this high content occurred inpractically all food product groups especially those ingroup VIII complete seasonings (18 700mg Na100 g)broths and soup powders (4500 mg Na100 g) and powdersfor sauce preparation (4442mg Na100 g)

Studies conducted in other countries have also foundhigh Na content in processed food products In Canada17 of the 364 products with Na information analysedhad high Na content(40) In the UK the highest meanNa content was found in broths and sauces (1090 mg100 g)(30) In Australia the mean Na content of broths was6108 mg100 g(29) Another Australian study(41) observed

Public

HealthNutrition

Table 1 Sodium content (mg100 g or 100 ml) and sodium content classification by group and subgroup of processed and ultra-processedpre-prepared meals and prepared ingredients food products marketed in Brazil used in lunch or dinner (n 1411)

Food product groups and subgroups n MediandaggerNa content

classificationDaggerPercentiles(P2ndashP98)dagger

P98P2ratiodagger

I ndash Bread products cereals legumes roots tubers and their derivatives 190 860 HighInstant pasta with or without seasoning 78 1632 High 288ndash2566 8middot9Dehydrated pasta with filling 3 590 Medium 530ndash780 1middot5Fresh pasta with and without filling 50 581 Medium 43ndash1099 25middot6Ready-made mixtures for ricerisotto preparation 12 44 Low 0ndash2170sect 434middot0Ready-made mixtures for flavoured polenta preparation 5 1544 High 1530ndash1704 1middot1Soya-based breaded steak meatball and hamburger preparations 10 587 Medium 506ndash1000 2middot0Ready-to-consume manioc flour 13 591 Medium 337ndash923 2middot7Frozen filled cheese bread 1 665 HighFrozen cheese bread without filling 6 527 Medium 302ndash774 2middot6Tofu 3 320 Medium 150ndash323 2middot2Frozen pre-fried potatoes and cassava 9 335 Medium 24ndash451 18middot8

II ndash Fresh and canned vegetables 221 425 MediumTriple vegetable concentrate (extract) 27 403 Medium 302ndash733 2middot4Vegetable pureacutee or pulp including tomato 6 68 Low 0ndash260 52middot0Tomato sauce or sauces with bases of tomatoes and other vegetables 77 472 Medium 0ndash1530sect 306middot0Pickles and capers 8 2167 High 713ndash3110 4middot4Dehydrated vegetable preserves (dried tomatoes) 3 1615 High 355ndash2223 6middot3Pickled vegetables (artichokes asparagus mushrooms peppers cucumberand palm hearts) in brine vinegar and oil

56 424 Medium 140ndash1476 10middot5

Garnishes and other canned vegetables and fruits (carrots peas cornpeeled tomatoes and others)

62 371 Medium 0ndash3170 634middot0

III ndash Fruits juices nectars and fruit drinks 15 0 LowFruit preserves including fruit salad 15 0 Low 0ndash30sect 6middot0

IV ndash Milk and derivatives 171 633 HighGrated cheese 26 707 High 50ndash1660 33middot2Minas cheese 18 319 Medium 133ndash1833 13middot8Other cheeses (ricotta semi-hard white cream cheese melted andpaste)

127 637 High 50ndash1800 36middot0

V ndash Meats and eggs 170 877 HighMeat preparations with flour or breading 32 650 High 149ndash932 6middot3Meat preparations ndash seasoned smoked and cooked or pre-cooked 18 767 High 100ndash1483 14middot8Sausages ham and cold ham 35 1700 High 885ndash3638 4middot1Sausages all kinds 50 1067 High 370ndash1575 4middot3Kani-kama 3 718 High 615ndash885 1middot4Tuna sardines fish shellfish other fish pickled with or without sauces 28 317 Medium 152ndash1020 6middot7Pickled eggs 4 56 Low 56ndash56 1middot0

VI ndash Oils fats and seeds 127 1550 HighOlives 62 1650 High 820ndash2400 2middot9Mayonnaise and mayonnaise-based sauces 35 1050 High 708ndash1233 1middot7Oil-based salad dressings (all kinds) 30 1119 High 383ndash6000 15middot7

VIII ndash Sauces ready-to-consume seasonings broths soups and prepareddishes

522 873 High

Concentrated broths (meat chicken vegetable and others) and souppowders

95 4500 High 2384ndash23726 10middot0

Ketchup and mustard 41 717 High 0ndash2975sect 595middot0Soya- or vinegar-based sauces 67 2836 High 100ndash5490 54middot9Sauces based on dairy or broth products 30 544 Medium 50ndash3556 71middot1Powders to prepare sauces 8 4442 High 3903ndash4978 1middot3Miso soup 2 4585 High 4530ndash4640 1middot0Missoshiru 2 6980 High 6910ndash7050 1middot0Prepared and semi-prepared dishes not included in other table items 208 475 Medium 54ndash1170 21middot7Complete seasonings 69 18 700 High 2620ndash40300 15middot4

Food product groups and subgroups according to RDC no 3592003(22)daggerNa in mg100 g or mg100mlDaggerMedian Na content classified according to the Traffic Light Labels of the Food Standards Agency UK(39)sectTo facilitate calculation in the cases in which the minimum value is zero the minimum value was considered= 5mg Na100 g according to RDC no 3602003(23)

Sodium in processed foods sold in Brazil 5

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

Public

HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

high mean Na content in broths (16 920mg100 g) andsoup powders (1882mg100 g) In a New Zealand studythe highest mean Na content was found in Asian sauces(5141 mg100 g) mustard (1779 mg100 g) and hot sauces(1549 mg100 g)(42)

Despite having some of the highest mean Na levels inthe present study and being constituted basically of saltcomplete seasonings and broths are not consumed in largeamounts within a single meal Nevertheless these pro-ducts are among the main Na sources in the Braziliandiet(2) Furthermore a meal can be comprised of severaltypes of food products(15) containing a combination ofhigh-Na processed foods One example of this is pastawith tomato sauce which can be composed of instantnoodles ready-made tomato sauce pickled olives ready-made seasoning and grated cheese and served with a sidesalad with ready-made dressing and cooked meat readyto be heated ndash all products with a potentially high Nacontent In a meal with this combination for examplethe Na content could exceed the recommended levelscompromising nutritional quality(5)

A large variation was also found in Na content betweensimilar products In 78middot0 of the subgroups analysed the

variation between the highest and lowest Na content wasat least twofold and could reach extreme differences suchas 634 times greater in the case of the garnishes and othercanned vegetables and fruits subgroup In some sub-groups (such as oil-based salad dressings) these largedifferences concurred with high Na content

An Australian study(29) that analysed 7221 processedfoods also found high Na content and large variations inNa concentration in most product categories analysedincluding salad dressings (181 times) A Brazilian study ofthe nutritional profiles of some processed foods(43) foundsimilar results but with shoestring potatoes presenting thegreatest variation (14middot3 times) The present study foundeven greater variation between the Na levels of similarproducts which may have occurred in some subgroupsdue to the inclusion of distinct products in the samesubgroup The resulting data asymmetry caused by thiscategorization can be observed in the lsquoother cheesesrsquosubgroup which includes both an example of ricottacheese with Na content lt100mg100 g and an exampleof parmesan cheese with Na content gt2000mg100 gHowever in most of the subgroups the difference isattributable to the presence of products with insignificant

Public

HealthNutrition

Table 2 Food additives containing sodium cited on the ingredients lists of processed and ultra-processed pre-preparedmeals and prepared ingredients marketed in Brazil used in lunch or dinner meals along with their citation frequencyand respective International Numbering System (INS)(3435) (n 1416)

Food additives containing Na INS n

Monosodium glutamate 621 505 35middot7Disodium 5prime-inosinate 631 208 14middot7Pentasodium triphosphate 451i 144 10middot7Sodium erythorbate (sodium isoascorbate) 316 103 7middot3Sodium benzoate 211 83 5middot9Sodium nitrite 250 81 5middot7Sodium polyphosphate 452i 58 4middot1Sodium nitrate 251 55 3middot9Tetrasodium diphosphate 450iii 55 3middot9Disodium 5prime-guanylate 627 53 3middot7Sodium carbonate 500 52 3middot7Calcium disodium ethylene diamine tetraacetate 385 48 3middot4Carrageenan 407 45 3middot2Sodium dihydrogen phosphate 339i 41 2middot8Trisodium citrate 331iii 36 2middot5Disodium diphosphate 450i 35 2middot5Trisodium phosphate 339iii 21 1middot5Sodium lactate 325 20 1middot4Sodium saccharin 954 19 1middot3Disodium hydrogen phosphate 339ii 18 1middot3Sodium stearoyl lactylate 481i 17 1middot2Sodium metabisulfite 223 15 1middot1Sodium aluminosilicate 554 10 0middot7Sodium carboxymethyl cellulose (cellulose gum) 466 8 0middot6Sodium alginate 401 6 0middot4Sodium hydrogen carbonate 500ii 5 0middot4Sodium caseinate 5 0middot4Sodium cyclamate 952 4 0middot3Sodium diphosphate 540i 3 0middot2Emulsifying salts 3 0middot2Sodium ascorbate 301 3 0middot2Sodium acetate 262i 2 0middot1Sodium hydrogen sulfite 222 2 0middot1Sodium sulfite 221 1 0middot07

Does not appear on Mercosulrsquos list of food additives(35)

6 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

amounts of Na according to Brazilian legislation in contrastwith similar products with extreme Na levels in the samesubgroup as is the case for tomato sauces for example

The large variation found shows that there are realopportunities to reformulate products available for sale inBrazil This situation demands a strong government policyto reduce Na content(44) as has occurred in the UK andFinland(18) and has been occurring in Brazil since 2010(45)Such policies involve the reformulation of food productsin order to reduce the supply ndash and thus the intake ndash of Nacoming from these products These policies combinedwith new proposals to require nutritional labelling on thefront of packages can influence the industry to reduce theNa levels of the foods they offer(3132)

Equally noteworthy is the high number of citations ofNa-containing food additives in the products studiedespecially monosodium glutamate According to a studydeveloped in China monosodium glutamate intake waspositively and longitudinally associated with BMI andoverweight among apparently healthy Chinese adults(46)In addition up to eight Na-containing food additives werefound in the same product ndash as in the case of cookedmeat with barbeque sauce (group V) ndash as well as sodiumdiphosphate which is not included on Mercosulrsquosharmonized list of additives and was found in 0middot3 of thefood analysed A review of food additives(47) raises theissue of adverse health effects caused by the use of foodadditives in large amounts

The reduction of all dietary Na sources (including foodadditives) is recommended by the WHO(6) In order toreduce Na intake it is recommended to inform the publicof high Na levels in foods(25) facilitating identification ofhigh-Na foods at the time of purchase However thefeasibility of this is questionable considering the way Na iscurrently labelled in Brazil

The Brazilian consumer currently has two ways tocheck for excessive Na content in processed foods (i) byreading Na information in milligrams per serving alongwith analysing the DV corresponding to the foodrsquos servingsize or (ii) by noting the appearance of Na-containingfoods (especially salt) on the ingredients list The presentstudy identified some points that could hinder thisexamination

The first point was the presentation of Na contentin milligrams per serving The present studyrsquos analyseswere only made possible after converting the Na value inmilligrams per serving to milligrams per 100 g or 100ml offood Interpretation was made difficult by the manner inwhich nutrition label information is presented (withvarying serving sizes) and the fact that Brazilian nutritionlabelling legislation(22) permits serving size variability Itshould be noted that the public generally does notunderstand information in milligrams or the conversion ofNa to salt Furthermore the terms lsquosodiumrsquo and lsquosaltrsquo arestill erroneously used as synonyms(4849) One suggestedalternative is to present Na content per 100 g instead of by

serving size precisely because of the variability allowedin serving sizes which in many cases prevents easycomparison between foods(50)

Another difficulty concerns the DV calculation basedon 2400 mg Nad(23) The use of this value extrapolates theWHO and FAO(17) recommended daily intake by 400 mgThe presentation of a value above the recommendedvalue can confuse consumers as discussed in a review ofNa intake in Canada(49)

Finally it was expected that higher Na content couldcorrespond to a higher number of salt citations in theinitial position of the ingredients list However the presentstudy did not find this rule to be a good indicator to checkfor high Na levels in food products because among otherreasons the proportion of added salt is still small comparedwith the proportion of other ingredients added to theproduct such as processed food with few ingredientslike tomato pureacutee (made with tomatoes and salt) or foodproducts with an elevated proportion of a main ingredientsuch as flour or meat A Chinese study(51) that analysed theingredients lists of 5877 food products found salt listed asone of the first three ingredients on 22middot9 of them yethighlighted the difficulty in judging product quality simplyby reading the ingredients list and consequently consumersrsquodifficulty in identifying processed food ingredients related tothe development of chronic non-communicable diseases

Our study also incorporates some possible limitationsthat should be taken into consideration One possiblelimitation of the present study is the use of nutritionlabelling to determine a productrsquos Na content withoutrunning chemical analyses However the study con-sidered that consumers only have access to what isreported on packaging so the accuracy of such informa-tion should be ensured by the manufacturer and tested forcompliance with the legislation(23) Another potential lim-itation of the study was the inclusion of products sold injust a single store but since the store is a large super-market in an urban area that offers a wide variety of foodproducts and belongs to a large chain most of theproducts sold there are sold by other chains and storesthroughout the country so this fact is unlikely to affect thestudyrsquos external validity Finally the productsrsquo presentationin predefined groups and subgroups by Brazilian labellinglegislation can also be considered a limitation Howeverdespite making it impossible to specifically analyse eachtype of food product the study settled on using the pre-defined groups and subgroups because this is the officialcategorization under current labelling law in Brazil(22)which regulates the presentation format of nutritionalinformation available at the time of purchase

Conclusions

Most of the processed and ultra-processed food productsincluded in the present study had high Na content and

Public

HealthNutrition

Sodium in processed foods sold in Brazil 7

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

high variability among similar products which presentsnew evidence for reformulation opportunities in foodproducts sold in Brazil These products are widely con-sumed by Brazilians underscoring the urgency of redu-cing Na content in these products as excessive Naconsumption has a negative impact on health outcomesincluding an increased risk of developing chronic non-communicable diseases It is clear that Na labelling shouldbe reviewed since current labelling was found not tofacilitate the identification of Na content or its variationamong similar products Aiming to ensure the usefulnessof information provided to consumers and the nutritionalquality of products sold we recommend a reduction of Nacontent in food products in Brazil as well as the continueddevelopment of studies aiming to improve Brazilian Nalabelling with a focus on easier identification of high-Naproducts at the time of purchase

Acknowledgements

Financial support This research was supported by theCouncil for the Development of Postgraduate Personnel(Coordenaccedilatildeo de Aperfeiccediloamento de Pessoal de NiacutevelSuperior CAPES) and the Santa Catarina State Researchand Technological Innovation Assistance Foundation(Fundaccedilatildeo de Amparo agrave Pesquisa e Inovaccedilatildeo Tecnoloacutegicado Estado de Santa Catarina FAPESC) CAPES and FAPESChad no role in the design analysis or writing of thisarticle Conflict of interest None Authorship CAM wasresponsible for the study design project managementdata analysis interpretation of the results and manuscriptwriting DAG-C was responsible for the data analysisinterpretation of the results and revision of the finalmanuscript RPdCP AAdS and MBV were responsiblefor the design of the original study research coordinationorientation and revision of the final manuscript Ethics ofhuman subject participation Ethical approval was notrequired

References

1 US Department of Agriculture amp US Department of Healthand Human Services (2010) Dietary Guidelines forAmericans httpwwwhealthgovdietaryguidelinesdga2010DietaryGuidelines2010pdf (accessed March 2011)

2 Sarno F Claro RM Levy-Costa RB et al (2009) Estimatedsodium intake by the Brazilian population 2002ndash2003 RevSaude Publica 43 219ndash225

3 Brown IJ Tzoulaki I Candeias V et al (2009) Salt intakesaround the world implications for public health Int JEpidemiol 38 791ndash813

4 Tanase CM Griffin P Koski KG et al (2011) Sodium andpotassium in composite food samples from the CanadianTotal Diet Study J Food Compost Anal 24 237ndash243

5 Instituto Brasileiro de Geografia e Estatiacutestica (2011) Pesquisade Orccedilamentos Familiares 2008ndash2009 Analise do consumoalimentar pessoal no Brasil Rio de Janeiro IBGE

6 World Health Organization (2007) Reducing salt intakein populations Report of a WHO Forum and TechnicalMeeting httpwwwwhointdietphysicalactivitySalt_Report_VC_april07pdf (accessed May 2011)

7 Uzan A amp Delaveau P (2009) The salt content of food apublic health problem Ann Pharmaceut Franc 67291ndash294

8 Anderson CAM Appel LJ Okuda N et al (2010) Dietarysources of sodium in China Japan the United Kingdomand the United States women and men 40 to 59 years TheINTERMAP Study J Am Diet Assoc 110 736ndash745

9 Monteiro CA Levy-Costa RB Claro RM et al (2010) A newclassification of foods based on the extent and purpose oftheir processing Cad Saude Publica 26 2039ndash2049

10 Monteiro CA Levy-Costa RB Claro RM et al (2011)Increasing consumption of ultra-processed foods and likelyimpact on human health evidence from Brazil PublicHealth Nutr 14 5ndash13

11 Hoy MK Goldman JD Murayi T et al (2011) Sodium intakeof the US population What We Eat in America NHANES2007ndash2008 httpwwwarsusdagovsp2userfilesplace12355000pdfdbriefsodium_intake_0708pdf (accessedMarch 2012)

12 Instituto Brasileiro de Geografia e Estatiacutestica (2010) Pesquisade Orccedilamentos Familiares 2008ndash2009 Aquisiccedilao alimentardomiciliar per capita Rio de Janeiro IBGE

13 Levy-Costa RB Sichieri R Pontes NS et al (2005) Householdfood availability in Brazil distribution and trends (1974ndash2003)Rev Saude Publica 39 530ndash540

14 Maciel MA (2004) Uma cozinha a brasileira Est Hist 3325ndash39

15 Barbosa L (2007) Feijao com arroz e arroz com feijao oBrasil no prato dos brasileiros Horiz Antropol 13 87ndash116

16 Brasil Ministerio da Saude Secretaria de Atenccedilao a MulherDepartamento de Atenccedilao Brasiliacutea (2012) National Policyfor Food and Nutrition Brasiacutelia DF Ministerio da Saude

17 World Health Organization (2003) Diet Nutrition and thePrevention of Chronic Diseases Joint WHOFAO ExpertConsultation WHO Technical Report Series no 916 GenevaWHO

18 Webster JL Dunford EK Hawkes C et al (2011) Saltreduction initiatives around the world J Hypertens 291043ndash1050

19 World Health Organization (2004) Global Strategy on DietPhysical Activity and Health Fifty-seventh World HealthAssembly List of All Documents and Publications httpwwwwhointhprgsalldocsshtml (accessed June 2009)

20 World Health Organization amp Food and AgricultureOrganization of the United Nations (2007) Food Labelling5th ed Rome FAO available at ftpftpfaoorgdocrepfao010a1390ea1390e00pdf

21 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaacuteria (2000) Resoluccedilao da Diretoria Colegiada ndash RDCno 94 de 23 de dezembro de 2000 aprova regulamentotecnico para rotulagem nutricional obrigatoria de ali-mentos e bebidas embalados Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

22 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 359 de 23 de dezembro de 2003 aprova regulamentotecnico de porccedilotildees de alimentos embalados para fins derotulagem nutricional Brasiacutelia DF Diario Oficial [da]Republica Federativa do Brasil Poder Executivo

23 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2003) Resoluccedilao da Diretoria Colegiada ndash RDCno 360 de 23 de dezembro de 2003 aprova regulamentotecnico sobre rotulagem nutricional de alimentos embaladostornando obrigatoria a rotulagem nutricional Brasiacutelia DFDiario Oficial [da] Republica Federativa do Brasil PoderExecutivo

Public

HealthNutrition

8 CA Martins et al

24 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2002) Resoluccedilao da Diretoria Colegiada ndash RDC no259 de 20 de dezembro de 2002 aprova regulamento tecnicopara rotulagem de alimentos embalados Brasiacutelia DF DiarioOficial [da] Republica Federativa do Brasil Poder Executivo

25 Brasil Ministerio da Saude (2008) Feeding Guide for theBrazilian Population Promoting the Health Food BrasiacuteliaDF Ministerio da Saude

26 National Health Service NHS Choices (2013) Food labelshttpwwwnhsukLivewellGoodfoodPagesfood-labellingaspxIn (accessed April 2012)

27 Han H (2012) Low sodium diet J Renal Nutr 22 e11ndashe1328 Pietinen P Valsta LM Hirvonen T et al (2008) Labelling the

salt content in foods a useful tool in reducing sodium intakein Finland Public Health Nutr 11 335ndash340

29 Webster JL Dunford JK amp Neal BC (2010) A systematicsurvey of the sodium contents of processed foods Am J ClinNutr 91 413ndash420

30 Ni Murchu C Capelin C Dunford EK et al (2011) Sodiumcontent of processed foods in the United Kingdom analysisof 44000 foods purchased by 21000 households Am J ClinNutr 93 594ndash600

31 van Raaij J Hendriksen M amp Verhagen H (2009) Potentialfor improvement of population diet through reformula-tion of commonly eaten foods Public Health Nutr 12325ndash330

32 Vyth EL Steenhuis IHM Roodenburg AJC et al (2010) Front-of-pack nutrition label stimulates healthier product develop-ment a quantitative analysis Int J Behav Nutr Phys Act 7 65

33 Associaccedilao Brasileira de Supermercados (2013) RankingAbras as 500 maiores httpwwwalasnetorgalasimagesasociadosabrasranking20abras202013esppdf (accessedJuly 2013)

34 Brasil Ministerio da Saude Agencia Nacional de VigilanciaSanitaria (2010) Resoluccedilao da Diretoria Colegiada ndash

RDC no 45 de 03 de novembro de 2010 aprova reg-ulamento tecnico sobre aditivos alimentares autorizadossegundo as Boas Praticas de Fabricaccedilao (BPF) BrasiacuteliaDF Diario Oficial [da] Republica Federativa do Brasil PoderExecutivo

35 Brasil Agencia Nacional de Vigilancia Sanitaria (2011) ListaGeral Harmonizada no Mercosul de Aditivos Alimentares esuas Classes Funcionais httpportalanvisagovbrwpswcmconnecteacf2e004745977ea06cf43fbc4c6735Tabela_Aditivo_GMC11-2006_LGHpdfMOD=AJPERES (accessedOctober 2011)

36 Galeazzi MAM Domene SMA amp Sichieri R (organizers)(1997) Estudo Multicentrico sobre Consumo Alimentarhttpwwwunicampbrnepaarquivo_sancadernosespecialpdf (accessed August 2011)

37 Federaccedilao das Industrias do Estado de Sao Paulo ampInstituto Brasileiro de Opiniao Publica (2010) Brazil Food

Trends 2020 httpwwwbrasilfoodtrendscombr (accessedSeptember 2011)

38 Souza AM Pereira RA Yokoo EM et al (2013) Most con-sumed foods in Brazil National Dietary Survey 2008ndash2009Rev Saude Publica 47 1 Suppl 190Sndash199S

39 Food Standards Agency UK (2007) Front of pack traffic lightsignpost labelling technical guidance httpwwwfoodgovukmultimediapdfsfrontofpackguidance2pdf (accessedMay 2011)

40 Elliott C (2008) Assessing lsquofun foodsrsquo nutritional content andanalysis of supermarket foods targeted at children Obes Rev9 368ndash377

41 Grimes CA Campbell KJ Riddell LJ et al (2011) Sources ofsodium in Australian childrenrsquos diets and the effect of theapplication of sodium targets to food products to reducesodium intake Br J Nutr 105 468ndash477

42 Woodward E Eyles H amp Ni Murchu C (2012) Key oppor-tunities for sodium reduction in New Zealand processedfoods Aust N Z J Public Health 36 84ndash89

43 Brasil Agencia Nacional de Vigilancia Sanitaria (2013)Informe Tecnico no 54 de julho de 2013 teor de sodio nosalimentos processados httpportalanvisagovbrwpswcmconnect8ab9538040695edd83fed3dc5a12ff52INFORME+TC389CNICO+JULHO+2013pdfMOD=AJPERES (accessedJuly 2013)

44 Webster J Dunford E Kennington S et al (2014) Drop theSalt Assessing the impact of a public health advocacystrategy on Australian government policy on salt PublicHealth Nutr 17 212ndash218

45 Brasil Ministerio da Saude (2011) Construccedilatildeo da agenda dereformulaccedilao de alimentos processados com as industriasde alimentaccedilao httpwwwnutriccedilatildeosaudegovbrsoacutedio_reformulacaophp (accessed October 2011)

46 He K Du S Xun P et al (2011) Consumption of mono-sodium glutamate in relation to incidence of overweight inChinese adults China Health and Nutrition Survey (CHNS)Am J Clin Nutr 93 1328ndash1336

47 Polocircnio MLT amp Peres F (2009) Food additive intake andhealth effects public health challenges in Brazil Cad SaudePublica 25 1653ndash1666

48 McLean R amp Hoek J (2014) Sodium and nutrition labellinga qualitative study exploring New Zealand consumersrsquo foodpurchasing behaviours Public Health Nutr 17 1138ndash1146

49 Van Vliet BN amp Campbell NRC (2011) Efforts to reducesodium intake in Canada why what and when Can JCardiol 27 437ndash445

50 Sharp D (2004) Labelling salt in food if yes how Lancet364 2079ndash2080

51 Ly J Chen Y Wang S et al (2011) A survey of nutritionlabels and fats sugars and sodium ingredients in com-mercial packaged foods in Hangzhou China Public HealthReports 126 116ndash122

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HealthNutrition

Sodium in processed foods sold in Brazil 9