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

Goiana-da-Silva, Francisco; Cruz-e-Silva, David; Rito, Ana; Lopes, Carla; Muc, Magdalena; Darzi, Ara; Araújo, Fernando; Miraldo, Marisa; Morais Nunes, Alexandre and Allen, Luke N. (2022). Modeling the health impact of legislation to limit the salt content of bread in Portugal: A macro simulation study. Frontiers in Public Health, 10, article no. 876827.

DOI: https://doi.org/10.3389/fpubh.2022.876827

Abstract

Background
Excessive salt consumption—associated with a range of adverse health outcomes—is very high in Portugal, and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4 g salt per 100 g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0/100 g by 2022, however the legislation was vetoed by the European Commission on free-trade grounds.

Aims
To estimate the health impact of subjecting imported and traditional breads to the current 1.4 g threshold, and to model the potential health impact of implementing the proposed 1.0 g threshold.

Methods
We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modeling tool to estimate the number of salt-related deaths that would have been averted in 2016 (the latest year for which all data were available) from; (1) Extending the 1.4 g threshold to all types of bread, and (2) Applying the 1.0 g threshold to all bread sold in Portugal. We used Monte Carlo simulations to generate confidence intervals.

Results
Applying the current 1.4 g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95% CI: 43–172). Lowering the current threshold from 1.4 to 1.0 g and applying it to all bread products would reduce daily salt consumption by 3.6 tons per day, saving an estimated 286 lives a year (95% CI: 123–454).

Conclusions
Salt is an important risk factor in Portugal and bread is a major source. Lowering maximum permissible levels and removing exemptions would save lives. The European Commission should revisit its decision on the basis of this new evidence.

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