AUTHOR=Goiana-da-Silva Francisco , Cruz-e-Silva David , Rito Ana , Lopes Carla , Muc Magdalena , Darzi Ara , Araújo Fernando , Miraldo Marisa , Morais Nunes Alexandre , Allen Luke N. 

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

JOURNAL=Frontiers in Public Health

VOLUME=Volume 10 - 2022

YEAR=2022

URL=https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2022.876827

DOI=10.3389/fpubh.2022.876827

ISSN=2296-2565

ABSTRACT=Background: Salt consumption in Portugal is among the highest in Europe and bread is the second largest source. Current Portuguese legislation sets a maximum limit of 1.4g salt per 100g bread, but imported and traditional breads are exempted. In 2017 the Ministry of Health proposed reducing the salt threshold to 1.0g/100g 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 1.4g threshold, and to model the health impact of implementing the proposed 1.0g threshold. 

Methods: We gathered bread sales, salt consumption, and epidemiological data from robust publicly available data sources. We used the open source WHO PRIME modelling 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 1.4g threshold to all types of bread, and 2) Applying the 1.0g threshold to all bread sold in Portugal. We used Monte Caro simulations to generate confidence intervals. 

Results: Applying the current 1.4g threshold to imported and traditional bread would have averted 107 deaths in 2016 (95%CI: 43 to 172). Lowering the current threshold from 1.4 to 1.0g and applying it to all bread products would reduce daily salt consumption by 3.6 tonnes 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.