限盐警告势在必行

诸平

据2019年9月27日乔治全球健康研究所（George Institute for Global Health）提供的消息，世界高血压联盟(World Hypertension League)和领先的国际卫生组织表示，超市出售的食盐和餐馆里的盐瓶都应要求在包装正面印有烟草式的健康警告。盐作为人们日常生活中必不可少重要的调味品之一，适量对于健康有益。但是，在实际生活中“限盐”已经成为一个老生常谈的健康生活方式的话题。虽然说清淡、少盐有益于健康，但是我国百姓的日常食盐摄入量依然超标，世界控盐形势也不容乐观。2019年9月25日在《临床高血压》（ Journal of Clinical Hypertension）杂志网站上发表的一篇文章——Norm R. C. Campbell，Jacqui Webster，Adriana Blanco‐Metzler，Feng J. He，Monique Tan，Graham A. MacGregor，Francesco P. Cappuccio，JoAnne Arcand, Kathy Trieu, Clare Farrand, Alexandra Jones, Paul K. Whelton, Xin‐Hua Zhang. Packages of sodium (Salt) sold for consumption and salt dispensers should be required to have a front of package health warning label: A position statement of the World Hypertension League, national and international health and scientific organizations. The Journal of Clinical Hypertension, 2019, DOI: 10.1111/jch.13698. First published: 25 September 2019. https://doi.org/10.1111/jch.13698. 此研究报告的第一作者，是世界高血压联盟（World Hypertension League）前主席诺姆·坎贝尔博士（Dr. Norm R. C. Campbell），也是论文的通讯作者。

诺姆·坎贝尔博士表示，现在是时候采取更有力的措施来减少饮食中的盐了。专家指出，食盐包装或者盛盐瓶应该带有类似香烟包装上标注的“吸烟有害健康”字样的健康警告——“过量摄入盐会导致高血压和胃癌。”

 “不健康的饮食是全球死亡的主要原因，而过量的盐摄入是最大的罪魁祸首，据估计，2017年全球有300多万人死于盐摄入过多。”坎贝尔博士补充说：“世界卫生组织为各国设定了到2025年将钠摄入量减少30%的目标，各国政府和食品行业一直在共同努力减少加工食品中的盐。然而，现在需要采取紧急行动，提高消费者对这些危险的认识。”

他说:“尽管许多国家已经开始研究各种公共卫生措施，鼓励人们少吃盐，但我们还没有发现任何要求在实际盛盐容器上面贴上警告标签的措施。”

世界卫生组织乔治全球健康研究所人口减盐合作中心主任雅克·韦伯斯特（Jacqui Webster）评论说:“吃太多盐会增加人们的血压，而血压是导致中风或心脏病过早死亡的最大因素之一。”

“尽管大多数国家都要求加工食品的标签上标明钠含量，但人们很难解读这些标签，也不会对任何健康风险发出警告。”

她补充说:“在食盐包装和分配器上发出健康警告，将是向全世界数十亿人传达盐的危险的一种简单、划算的方式。”

“大多数人都没有意识到，他们摄入的盐量正在提高他们的血压，缩短他们的寿命，”汤姆·弗里登博士（Dr. Tom Frieden）说。包装食品和菜单上的警告标签可以帮助人们做出更健康的选择。在所有的盐包装上添加警告标签是另一种让健康选择成为简单选择的方法。”

研究人员提出了如下警告:“过量的钠会导致高血压和胃癌。限制您的使用”。

更多信息请注意浏览原文或者相关报道。

How salt increases blood pressure

Dietary risks in aggregate are the leading risk for death globally. Among dietary risks, high dietary sodium (salt) is the leading risk.1 Globally, excess dietary sodium is estimated to have caused over 3 million deaths and over 70 million disability‐adjusted life‐years (DALYS) in 2017.1, 2 High dietary sodium is predominantly a risk as a result of increasing blood pressure (the leading single risk for death globally) but is also a probable pro‐carcinogen for gastric cancer, directly causes cardiovascular and renal damage independent of blood pressure, and is associated with several other diseases.1, 3-11 The recent National Academy of Medicine review of the evidence for dietary sodium consumption in United States and Canada concluded that excess dietary sodium increases blood pressure, that elevated blood pressure causes cardiovascular disease (CVD) and that there is moderately strong evidence that high dietary sodium directly increases total mortality and cardiovascular events.12 In addition, the World Health Organization (WHO) reported that increased dietary sodium increases blood pressure and is associated with CVD.13 Multiple other diseases have associations and biologically sound pathophysiological mechanisms for sodium causing harm, but clinical evidence is not substantive enough to prove causality.3 In addition, acute ingestion of sodium chloride (salt) in the range of 17 g or more in an adult, and 12.5 g or more in an infant can cause seizures, coma, and death. Although ingestions of large quantities of sodium are very distasteful and believed to be infrequent, both accidental and intentional deaths do occur.12, 14

Reducing excess dietary sodium is a global target of the WHO endorsed by the World Health Assembly, and many countries have started to reduce dietary sodium using a variety of public health interventions.15 The WHO created the SHAKE package to guide countries on policies to reduce dietary sodium.16 In most countries where most foods consumed are highly processed, the major source of sodium is from processed foods (ie, hidden sodium) with about 10% coming from sodium added in cooking and at the table (ie, discretionary sodium).16 Although most countries require the amount of sodium to be indicated on labels in processed foods (ie, nutrition fact panels [NFP]), these labels are difficult for consumers to interpret and do not warn of any risks from consumption.17 In general, NFP do not indicate if a product is high, intermediate, or low in sodium. A few other countries such as the United Kingdom have voluntary front of package warning labels for foods high in sodium. Several countries (eg, Finland, Israel, Iran, Chile, Uruguay, Ecuador, Peru), where sodium in processed foods is the major source, require warning labels on processed foods high in sodium and other countries are considering such labels.18 Front‐of‐pack labeling of this kind to reduce sodium intake is recommended by WHO as a “best buy” for NCD prevention.19 These labels are applicable to foods but not to packages of salt where the only content is sodium chloride.

In much of the world, the major source of sodium is that added as table salt in cooking and at the table.16, 20 Some countries have banned restaurants from putting salt shakers on tables to reduce spontaneous addition of sodium to foods and increase awareness of the dangers of high‐sodium diets (eg, Argentina, Uruguay, Mexico City). To our knowledge, no country has required actual packages and containers of sodium chloride (salt) to have warning labels.

Warning labels on packages of sodium chloride (see text box for an example) may have several potential benefits. Firstly, it would increase awareness of the dangers of high‐sodium diets by people purchasing sodium and a reminder of the dangers by people seeing the containers at stores, food service establishments, or in the home. Secondly, stores that sell sodium chloride may display sodium less prominently. Thirdly, and most importantly, it could lead to a reduction in sodium consumption. A randomized controlled trial found that having patients with hypertension place a warning label on salt shakers at home reduced sodium consumption very substantively.21 To have maximum impact, a warning label should also be considered for other major discretionary sources of dietary sodium (eg, soya sauce, fish sauce, bouillon cubes) where sodium is the major component of the product. Low sodium salts (with partial replacement of sodium by potassium and potentially magnesium) should also have a label that promotes use to help reduce dietary sodium but also a warning to reduce consumption and for people with kidney disease or taking antihypertensive or cardiac drugs to seek medical advice before using (to prevent hyperkalemia).

Efforts to reduce excess sodium from discretionary and processed food sources are compatible with the programs to prevent iodine deficiency disorders that use iodized sodium chloride. WHO has recommended coordination of population surveys of dietary sodium and iodine and to adjust the iodine content of sodium chloride based on changes in sodium intake.22, 23

This position statement requests governments require health warnings on packages of sodium chloride (salt) sold for consumption and sodium dispensers. The warning label should be clearly visible and easily readable, indicating that consumption of excess sodium is a health risk and advising consumers to use less sodium. A sample warning label is provided in the text box below.

Too much sodium in the diet causes high blood pressure and increases risk of stomach cancer, stroke, heart disease and kidney disease. Limit your use

The following organizations support the position. World Hypertension League, Resolve to Save Lives, World Health Organization Collaborating Centre on Salt Reduction, The George Institute for Global Health, World Action on Salt and Health (WASH), Consensus Action on Salt and Health (CASH), World Health Organization Collaborating Centre for Nutrition, University of Warwick, Hypertension Canada, and the British and Irish Hypertension Society.

ACKNOWLEDGMENTS

The authors thank Michael F. Jacobson, PhD for providing comments on drafts.

CONFLICT OF INTEREST

NRCC was a paid consultant to the Novartis Foundation (2016‐2017) to support their program to improve hypertension control in low‐ to middle‐income countries which includes travel support for site visits and a contract to develop a survey. NRCC has provided paid consultative advice on accurate blood pressure assessment to Midway Corporation (2017) and is an unpaid member of World Action on Salt and Health (WASH). JW is Director of the World Health Organization Collaborating Centre on Population Salt Reduction. She is supported by an Australian National Heart Foundation Future Leaders Fellowship and receives funding from WHO, the Australian National Health and Medical Research Council, Victorian Health Promotion Foundation and Vital Strategies for work on salt reduction. GAM is Chairman of Blood Pressure UK (BPUK), Chairman of Consensus Action on Salt & Health (CASH), WASH and Action on Sugar. BPUK, CASH, WASH and Action on Sugar are non‐profit charitable organizations. GAM does not receive any financial support from any of these organizations. FC is President and Trustee, British and Irish Hypertension Society; World Health Organization Scientific Advisor; Member of CASH and WASH. FJH is an unpaid member of CASH and WASH. MT, CF, KT JW, AJ, PW, and XHZ have no conflicts of interest to disclose.

POSITION STATEMENT

Commercially sold or provided (eg, in restaurants) packages or containers of sodium chloride (salt) intended for consumption and salt dispensers should be required to have a front of package health warning label. The warning label should be clearly visible, easily readable, indicate that consumption of excess sodium (salt) is a health risk, and recommend that people use less sodium (salt).

众所周知，过量摄入食盐是引发高血压、冠心病、中风等疾病的重要因素之一。并且之前已有研究显示中国居民食盐摄入量偏高，并引起有关方面重视。中国2019年发布的《国务院关于实施健康中国行动的意见》中，明确提出鼓励全社会参与减盐。

研究人员回顾分析了众多关于中国居民摄入食盐的文献数据，共涉及900名儿童和2.6万名成年人。分析结果表明，中国居民过去40年中食盐摄入量一直居高不下，同时南北还存在巨大差异。

研究人员指出，中国北方居民食盐摄入量为平均每天11.2克，较20世纪80年代时的12.8克有所减少。他们认为这与中国政府在提高全民减盐认识方面的努力密不可分，当然也包括人民生活条件的不断提高而对腌菜等食品的依赖逐渐减少有关。

同时研究还显示，3岁至6岁儿童食盐摄入量到达了世卫组织建议成人食盐摄入量的最高值，而年龄更大的孩子平均每天食盐摄入量则接近9克。

研究人员表明：“中国大部分食盐摄入来自家庭烹饪用盐，而当前更需要关注的是加工食品、街头小吃、餐馆和各种快餐连锁店的快速发展及相关食品中的含盐量。