Salt in bread in Europe: potential benefits of reduction
Joan Quilez and Jordi Salas-Salvado
In this respect, it has been shown that a reduction in the salt content of bread is
possible, and an alternative approach involves partial replacement with other,
mainly potassium-based salts, which also counteract the effects of sodium. This
replacement should be undertaken on the basis of criteria that maintain the
product's sensory profile, and it tends to be more successful in breads with more
Europe and the health problems associated with its excessive consumption;
particular focus is placed on the salt content of bread and the effects of its possible
reduction and/or correction. The beneficial effects of such changes are highlighted
by way of a theoretical calculation in baguette-type wheat bread. European
legislation in the field of nutrition and health claims allows the positive aspects of
such salt reduction and replacement methods to be stated.
© 2012 International Life Sciences Institute
Bread is one of the oldest prepared foods known to be
consumed by humans. As a result, bread also has enor-
mous symbolic significance,1with numerous references
to it in historical and religious texts both as an important
part of the diet and as a metaphor for various types of
nourishment. Over time, the bread-making process
remained relatively unchanged, until industrial produc-
tion resulted in significant changes in the process itself
and in the ingredients used.
Like bread, salt (NaCl) is a dietary component with
origins that can be traced back toAncient Egypt.Its main
initial use was as a food preservative, but advances in
food-preservation techniques, including refrigeration, in
Nevertheless, the boom in semi-prepared food products
and their popularity with consumers has led to relatively
high levels of salt consumption, especially in industrial-
ized countries.2Furthermore, as salt consumption has
been associated with raised blood pressure (BP) and car-
diovascular diseases (CVD), a variety of initiatives have
been undertaken,or are currently under way,at different
levels, to reduce its consumption.3
From an evolutionary viewpoint,high salt intake is a
relatively recent phenomenon. Natural selection has
resulted in only minor variations since the advent of agri-
culture in the Neolithic Period, and our bodies are
adapted for and accustomed to the hunter-gatherer diet
and lifestyle of the Paleolithic period.4The huge dietary
changes that occurred during the 20thcentury, therefore,
tend to be incompatible with our metabolic system and
often produce a series of diseases as a result.5Apart from
one of the main discrepancies that has been noted is
the large difference in sodium (Na) and potassium (K)
25% that estimated for the Paleolithic Period,whereas Na
in the Na/K ratio, which is currently 0.13–2.51 in mmol,
requires constant metabolic work to remove the excess
Na that would otherwise result in hypertension.7Like-
wise, as a result of the fact that Na is consumed as its
chloride (Cl-) and K as bicarbonate-producing salts,
Affiliations: J Quilez and J Salas-Salvado are with the Human Nutrition Unit, School of Medicine, IISSPV, Universitat Rovira iVirgili, Reus,
Spain, and CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain.
Correspondence: J Quilez, Human Nutrition Unit, School of Medicine, Universitat Rovira IVirgili, Sant Llorenç 21, 43201 Reus, Spain. E-mail:
email@example.com. Phone: +34-977-75-93-13. Fax: +34-977-75-93-22.
Key words: bread, potassium, salt, sodium
Nutrition ↔ Science Policy
Nutrition Reviews® Vol. 70(11):666–678
imbalance in the HCO3-/Cl-ratio, which is displaced
toward the latter and therefore has an acidifying effect,8
especially when high-protein diets are consumed. This
low-level acidosis leads to a greater excretion of calcium
and to bone-, kidney- and muscle-related diseases.9
The aim of the present review was to evaluate salt
intake in Europe and the health problems associated with
its excessive consumption, with particular focus on the
role played by the salt content of bread. Also examined
from various viewpoints are the potential consequences
of reducingtheamountof saltinbread,andthebeneficial
effects of such changes are highlighted by way of a theo-
retical calculation based on baguette-type wheat bread.
BREAD AND SALT
complex carbohydrates and proteins, B- group vitamins,
minerals, and fiber, especially whole-meal bread.10
However, in Europe, the term “bread” refers to a very
broad range of products. For example, in southern
Europe, bread has traditionally been made using wheat
flour, whereas many breads in central and northern
Europe contain rye flour.Likewise,the use of acid doughs
(e.g.,sourdough,levain,and lievito naturale),or leavened
starter sponge,is common in many countries.The degree
of flour extraction, which ranges from refined to whole-
meal, is another important aspect. As can be seen in
Table 1, which shows the bread consumption figures per
capita for several countries, bread consumption in
Europe has been on the decline in the past few years,with
a current average consumption rate of 170 g/day.
Despite the fact that salt is one of the key ingredients
in bread recipes,in ancient times its use was very limited
due to its high cost, and its use subsequently increased
slowly.Thus,toward the end of the 18thcentury,bread in
France contained just 0.5% salt with respect to flour,
although this figure reached 1% in some regions. The
greatest change in salt content occurred with the indus-
trialization of bread making in the 20thcentury, when
rapid mass production techniques required salt to
homogenize the process and the resulting product,
thereby counteracting bread’s lack of flavor and reaching
values as high as 2%. It is interesting to note that some
European communities have remained on the sidelines as
Figure 1 Estimated intake of K and Na in the Paleolithic
Period (black) and nowadays (white) in Europe.
Data from Eaton et al.,6andTable 3.
Table 1 Per capita bread consumption in several
European countries in 2010.
CountryPer capita bread consumption
Data from the following sources:
aUIB (Union Internationale de la Boulangerie et de la
Boulangerie-Pâtisserie). Available at: http://www.uibaker.org/
bAIBI (Association Internationale de la Boulangerie Industrielle
– International Association of Plant Bakeries). Available at:
cData for 2008.
eHenderson et al. (2011)11; data for 2004.
Nutrition Reviews® Vol. 70(11):666–678
far as this trend is concerned. Thus, natives of Mallorca
(Balearic Islands) continue to eat salt-free bread despite
the huge influx of tourists to the island and the immigra-
tion boom of the 1960s.
In contrast to the general belief that salt added to
foodstuffs at home represents as much as 50% of domes-
tic consumption inWestern countries,a study conducted
by James et al.12found that this source represented only
15% of salt intake, with the remainder attributed to the
the salt added to processed foods (75%). These findings
were subsequently confirmed by Mattes and Donnelly,13
who reported values of 11.3%, 11.6%, and 77%, respec-
tively, for the same sources of salt intake. So a reduction
in salt intake will mainly require a reduction in the
amounts added to processed foods. In processed foods,
salt is now used as food ingredient, as a preservative, for
curing meat, to mask unpleasant tastes, to encourage
moisture retention, and to enhance flavor. Although in
some cases it is impossible to reduce the salt content of
foods, in many others it is possible to obtain processed
foods with lower sodium content. This is the case with
Bread is considered to be one of the most important
sources of dietary salt,14and recent findings from several
European countries suggest that in Ireland it accounts for
25.9% of total salt intake,15with corresponding values of
25.5% for Turkey,16,1724.8% for Belgium,1824.2% for
France,1919.1% for Spain,20and 19% for the UK.21
According to consumer taste tests, the optimal salt
content for white wheat bread has been reported to be
between 1.29%22and 1.43%.23In contrast,a similar study
undertaken in Argentina reported a value of 1.74%,24
which is much higher than expected and could be due to
salt content of bread from various European countries is
shown in Table 2.
The need to harmonize data regarding foodstuff compo-
sition in Europe for various purposes is of particular
importance.30Two of the main factors contributing to the
homogeneity of results and, therefore, our ability to
compare them, are the representative nature of the sam-
pling and the use of the same analytical methods. In the
case of bread, and depending on the source, the salt
content is determined by analyzing either Cl-or Na+and
applying the corresponding factor to calculate the salt
content. It would appear logical to calculate the salt
content by analyzing the Na content; therefore, it would
be useful to develop a Europe-wide technical guideline to
standardize this measurement. Indeed, existing regula-
tion on the provision of food composition information to
consumers makes the inclusion of salt content on each
product’s nutritional information label compulsory, and
salt content is calculated by multiplying the Na concen-
tration by 2.5.31
A further aspect that needs to be standardized is the
expression of the salt content of bread. Some countries
prefer to express the salt content based on the baker’s
recipe (BR).In this scenario,the salt content is expressed
with respect to the amount of flour in the original dough,
which means that, depending on the type of bread, pro-
cessing, shape/weight and baking time, water loss will
vary and affect the salt content of the final product, even
when the same formula is used. This leads to some con-
fusion, which should be eliminated, as far as the salt
content of the resulting bread is concerned. One sugges-
tion for standardization is to always express the salt
content of the final baked product that is eaten by the
EFFECTS OF DIETARY SODIUM AND POTASSIUM
certain limits, adjusting this concentration by eating,
excreting any excess,mainly in the urine,and modulating
theprocessbywayof variousmechanismsof control.The
overactivity of the sympathetic nervous system, which
Table 2 Salt content in bread from several European countries.
White and rye
aValues are means (range).
Na (mg/100 g)a
NaCl (%) (Na ¥ 2.54)a
Vieira et al.26
Castanheira et al.27
Observatoire du pain28
Mhurchu et al.29
Akpolat et al.16
Nutrition Reviews® Vol. 70(11):666–678
produces a vasoconstriction that reduces Na and water
filtration, is one of the factors known to alter this equi-
librium and increase the BP.32Another key factor is the
renin-angiotensin-aldosterone system, the activation of
which leads to release of angiotensin II, a powerful vaso-
Excretionof Nainurineover24 hisconsideredtobe
the best indicator of salt intake. The values found for
seen,in general,salt intake in Europe is very high (~10 g/
day). Countries exceeding this value, such as Italy and
Portugal(botharound12 g/day)andTurkey(16.6 g/day),
should consider a salt-intake reduction program, espe-
cially in bread due to its high per capita consumption
(Table 1). The adoption of active salt-intake reduction
policies can be justified by the significant relationship
found between salt excretion/consumption and blood
pressure and its associated cardiovascular risk.19,44,47The
risk of stroke, left ventricular hypertrophy, stomach
cancer, kidney stones,and
increased.3,48Finally, high salt intake has also been
indirectly linked to obesity, especially in children and
adolescents, due to their higher consumption of sugar-
sweetened soft drinks.49In the United States, the follow-
ing intake levels have been established for sodium:
adequate intake, 1.5 g/day; and tolerable upper intake,
2.3 g/day.50The reference intake in Europe is 2.4 g/day.31
One important point to consider is that individuals
in low socioeconomic status (SES) groups tend to have
higher blood pressure values, which is basically a reflec-
tion of the higher prevalence of overweight/obesity and
higher salt intake in these groups.51,52In this regard, a
study conducted in Northern Ireland,in which salt intake
was found to be higher in people from low SES groups
due to their higher consumption of processed foodstuffs,
should be noted.53A higher Na/K ratio in urine has also
been reported in people from low SES groups.54
Apart from total salt intake, salt sensitivity is an
important aspect to consider when assessing cardiovas-
cular risk arising from salt consumption. Salt sensitivity
is defined as the blood pressure change that occurs in
response to a change in salt intake, with the principal
effect being that the morbidity in salt-sensitive normo-
tensive subjects is the same as in hypertensive subjects.55
Salt sensitivity occurs with either hereditary or acquired
defects in renal function and is estimated to affect
around 40–50% of the population.56,57Due to the diffi-
culties in distinguishing salt-sensitive from salt-resistant
subjects using phenotypic attributes, most research in
this field has focused on genes and their salt sensitivity-
related polymorphisms.58This is a promising field as
low-salt foodstuffs in general, and bread in particular,
should be highly targeted toward this segment of the
Although Na and K are the main regulators of the body’s
fluid balance and,therefore,influence the cardiac output,
in contrast to Na, K has beneficial effects on BP.59In
epidemiologic studies, high-K diets have been associated
with decreased risk of CVD and stroke.60As noted above,
the K content in Westernized diets is relatively low com-
pared to in other healthy dietary patterns. This implies
that a large proportion of the population may now have
suboptimal K intakes.61Several mechanisms, such as
increased natriuresis,reduced sympathetic nervous activ-
ity, and a decreased pressor response to noradrenaline
and angiotensin II, seem to be involved in the
BP-lowering effect of potassium.62However, various
studies have been unable to reproduce these effects,63,64
the results, such as salt sensitivity.
In some animal models, the anion that accompanies the
Na has been found to directly influence the BP increase
by promoting renal tubular reabsorption to different
degrees. Thus, Cl-has been found to increase the BP
whereas citrate or phosphate do not,65and there is some
evidence that the pressor effect of Na in humans does not
appear when ingested as the bicarbonate.66,67
As far as K is concerned, the results obtained with
different anions vary widely.Thus,Overlack et al.68found
a greater BP reduction effect with citrate (K-Cit) than
with chloride, while two other studies found that
although the intake of potassium salts reduced BP, there
was no significant differences between them (KCl versus
K-Cit).69,70However, the use of K-Cit has been found to
be effective in preventing urine calcium excretion,71and
in increasing bone mass in patients with osteopenia by
neutralizing, in part, the acid load associated with the
EFFECTS OF SODIUM REDUCTION AND/OR POTASSIUM
INCREASE INTHE DIET
Although the effect of an acute decrease in salt intake is
not clear,and may even be adverse,74the meta-analysis by
He and MacGregor75found that a modest reduction in
salt consumption of 3 g/day predicts a fall in BP of 3.6 to
5.6/1.9 to 3.2 mm Hg (systolic/diastolic) in hypertensive
subjects and 1.8 to 3.5/0.8 to 1.8 mm Hg in normotensive
subjects. Likewise, the reduction in risk of stroke and
ischemic heart disease was 13% and 10%, respectively. In
addition, a decrease in salt intake was associated with an
increase in the efficacy of the hypertensive treatment.76A
further meta-analysis of cohort studies also found a 23%
Nutrition Reviews® Vol. 70(11):666–678
Table 3 Urinary 24-h sodium and potassium excretion and estimated daily salt intake in European countries.
Urinary Na (mmol/24 h)a
Urinary K (mmol/24 h)a
Salt intake (g/day)a,b
Vandevijvere et al.18
Laatikainen et al.35
Du Cailar et al.36
Venezia et al.37
Geleijnse et al.38
Polonia et al.39
Ribic et al.40
Ortega et al.41
Hulthen et al.42
Erdem et al.17
Khaw et al.43
Zhou et al.44
Henderson et al.45
aValues are means (SD).
bValues in italics are estimated values from Na content.
Abbreviations: M, male; F, female.
Nutrition Reviews® Vol. 70(11):666–678
the risk of CVD, associated with a reduction in sodium
intake from 10 to 5 g/day; which helps explain to the
observed decrease in mortality.55
From an economic viewpoint,in Norway it was esti-
mated that a reduction in the average salt intake of up to
6 g/day would result in an increase of 1.6 months in life
expectancy,and also in a net cost saving of $4.72 million/
year.77In another study conducted in the United States,a
decrease in dietary salt of 3 g/day would significantly
reduce the incidence of CVD, stroke, myocardial infarc-
tion, and mortality, with an associated estimated health-
care cost saving of between $10,000 million and $24,000
million/year for the whole country.78In light of these
findings, it would be interesting to determine the eco-
nomic impact, in terms of healthcare costs, of a progres-
sive reduction in salt intake in different European
As far as K is concerned,the meta-analysis published
by Geleijnse et al.79demonstrated that a mean increase of
44 mmol/day of K was associated with a decrease of
-2.42 mmHg in systolic BP and -1.57 mmHg in diastolic
BP. In contrast, a wider ranging study that assessed the
combined intake of Na and K found that a higher Na/K
ratio in diet was associated with an increased risk of CVD
that is stronger than what could be explained by Na or K
From a cost/efficacy viewpoint, a reduction in salt
intake is the best means of reducing BP and, indirectly,
the incidence of CVD in the general population,81as sup-
ported by all dietary recommendations.82,83Therefore,
since bread is an important contributor to salt intake
(generally accounting for between 20% and 25% of the
total), an active policy for this food product would
complement the reductions of salt in other foodstuffs.
The so-called functional food approach, which corrects
the mineral nutrient composition of the most common
processed foods at a reasonable cost, is likely to be par-
ticularly effective at producing immediate beneficial
REDUCTION OF SALT CONTENT IN BREAD
It has been known for some time that the level of salt in
food that consumers prefer is dependent on the amount
of salt that they typically consume and that this preferred
level can be lowered after Na intake is reduced.85Indeed,
one study has shown that a gradual reduction in the salt
content of bread from 2% BR to 1.5% BR was possible to
achieve with no significant differences observed in the
control group,86thereby confirming that a stepwise
reduction to a certain salt level is feasible. A similar
finding resulted from a study undertaken in Holland,
where the vast majority of consumers (85%) were unable
to detect a stepwise reduction in the salt content of
The presence of salt in bread dough changes the
dough’s rheology and delays subsequent fermentation,
thereby helping to protect long-shelf-life products. The
bread itself undergoes changes to the crust, to the crumb
color, and especially to the taste, with the latter currently
being the most important factor related to its use.88,89The
production of bread with a low salt content (up to 0.3%
BR) is technically feasible simply by making appropriate
changes to the bread-making process, and the resulting
product maintains the same qualities,except for taste.90,91
that can be applied to all production systems,involves the
nonhomogeneous distribution of salt in bread, which
allows a 28% reduction in salt content whilst maintaining
the saltiness intensity.92
Another option for reducing the salt content is its
partial replacement by other salts, normally potassium
chloride (KCl), although other alternatives such as
calcium chloride (CaCl2) or magnesium chloride
(MgCl2) have also been proposed. In all cases, it was
found that the replacement had no adverse effects on
dough rheology, especially when it accounted for less
than 50%,93,94and that the main drawback was organo-
leptic in nature. Specifically, KCl has a slightly metallic
or bitter aftertaste that becomes more noticeable as the
replacement percentage increases. In light of this,
various studies have assessed the organoleptic accept-
ability threshold. For example,Wyatt and Ronan95found
no significant differences between the control (100%
NaCl) and test (50/50% NaCl/KCl) breads, with the
highest-scoring bread in terms of acceptability having a
75/25% NaCl/KCl ratio. In contrast, Salovaara96found
significant differences with a 60/40 mixture but not with
an 80/20 mixture. The addition of potassium gluconate
to bread has also been examined, with good results.97
Replacement is not as critical in brown bread,98and the
use of a mixture of salts in which the Na content of the
resulting bread is reduced by 32.3% and the K content
increased by 34.8% has shown good results in terms of
the quality and taste of this type of bread.99Finally, in a
broad and systematic study involving the replacement of
NaCl with K salts, Braschi et al.100concluded that the
best results, other than the control, were obtained with a
70/30 ratio of K-Cit or a 1:1 mixture of KCl and potas-
sium bicarbonate; they also demonstrated the complete
bioavailability of the potassium incorporated using these
Other possibilities that
include commercial salt mixtures,101and salt from low-
sodium and high-potassium, -calcium, or -magnesium
sources.102The use of KCl together with Na glutamate or
Nutrition Reviews® Vol. 70(11):666–678
ribonucleotides to mask the bitter aftertaste is another
interesting alternative,103although the umami taste
means it tends to only to be used in the salt substitution
of meat products.
EUROPEAN SALT-REDUCTION INITIATIVES
In Europe, the Council of the European Union (EU) has
provided its support to the EU framework for national
salt initiatives to reduce salt intake,104and two countries,
namely Finland and the UK, have designed and applied
positive in both cases and may,therefore,serve as a guide
for other countries.3
Finland was the first European country to establish a
salt-reduction strategy in the late 1970s. This strategy
involved informational campaigns in the mass media,
cooperation with the food industry,and the implementa-
tion of salt-labeling legislation (see Legislation section
below) and managed to reduce salt consumption from a
value of 12 g/day in 1979 to 9 g/day in 2002, as well as
achieving a significant improvement in the Na/K ratio,as
calculated on the basis of Na excretion in urine.35
The target in the UK was to reduce salt consump-
tion from 9.5 g/day in 200345to 6 g/day (63% of the
initial value) by 2012, which would require a similar
reduction in the levels found in semiprepared products.
In the case of bread, this means a maximum sodium
content of 0.4% (1% salt) by 2012.105This initiative,
which was accompanied by a media campaign and the
establishment of a front-of-pack signpost labeling
system, had achieved a reduction of almost 1 g/day by
2008.46Reduction in the salt content of food is recom-
mended by the Food Standards Agency, and with a view
to their customers, the major supermarket chains tend
to oblige their suppliers to comply with these recom-
mendations. Due to the importance of large distribution
companies, this has a knock-on effect in the food indus-
try as a whole.
Almost all European countries, except those that
have opted for the legislative route, have proposed or are
drawing up consensus strategies with the food industry,
although these are currently less stringent than those
applied in Finland or the UK. For example, in 2002,
France recommended a 20% reduction in salt intake
(from 12 to 8 g/day) over the next 4 years,106which
affected bread by reducing the maximum recommended
limit from 2% to 1.8% BR.28In Spain, implementation of
the NAOS (nutrition,physical activity and the prevention
of obesity) strategy107resulted in an agreement with
bread manufacturers in 2005 to reduce the salt content
from 2.2% to 1.8% BR, and this target was achieved in
Nutrition and health claims
The first legal reference to salt content in Europe, which
established a legal provision to gradually reduce the salt
content of bread to 2% BR, equivalent to approximately
1.5% in the finished product, appeared in Belgium in
1976.108However,enforcement of this provision has been
limited, to say the least, and no further legal restrictions
on salt content appeared until 2009, when Portugal
passed a law restricting the salt content of bread to 1.4%
in the final product.109As noted above, legislation does
not appear to be the most appropriate mechanism for
achieving salt reduction, although the specific character-
istics of certain countries may make such measures nec-
essary,110provided that appropriate control mechanisms
are in place.
The interaction between foodstuffs and health has,
for many years, been overlooked as far as the European
legislative framework is concerned.In 2006,however,the
regulation on nutrition and health claims made on foods
was finally published,111even though the claims are
remain to be published once a common EU position is
reached. The nutrient profiles are based on the Na, satu-
rated fatty acid, and sugar content, and only working
documents have been published to date.112Nevertheless,
the regulation includes a series of nutrition claims for
aspects such as the Na content, which include the terms
“reduced” for reductions greater than 25%, “low” Na
content (<0.12 g/100 g),“very low” Na content (<0.04 g/
100 g), and“without” Na (<0.005 g/100 g).
The statement “source of” can be used for K, pro-
vided the amount of K exceeds 15% of the recommended
daily allowance (RDA) of 2,000 mg/day.113,114This RDA,
which is markedly lower than that established for the
United States (4,700 mg/day),50therefore allows all those
foods in which K is present in significant amounts
(>300 mg/100 g) to be labeled as a source of K.As far as
health claims are concerned, a new European regulation
proposes that when the food is reduced or low in sodium,
the claim “reducing consumption of sodium contributes
to the maintenance of normal blood pressure” is
maintaining blood pressure and allows inclusion of the
claim “potassium contributes to the maintenance of
normal blood pressure” when the food is at least a source
The Cl-content is associated with intake of NaCl (or
replacements,such as KCl,when appropriate) and has an
RDA of 800 mg/day, a value which is easily exceeded by
the daily salt intake.However,and similar to the situation
with Na and K, no tolerable upper intake level has been
Nutrition Reviews® Vol. 70(11):666–678
established in Europe.116In the United States, the
adequate intake for younger adults is 2.3 g/day and for
older adults and the elderly it is 2.0 and 1.8 g/day,
Tax increases for unhealthy foods or subsidies for healthy
foods with the aim of promoting healthy eating or
increasing funding for public health programs,have been
widely debated. Although such proposals receive little
support from either the general public (<3%),118or the
food industry,119there is a tendency to consider that food
taxes and subsidies have the potential to contribute to
healthy consumption patterns at the population level.120
Indeed, the World Health Organization has recom-
mended the use of fiscal policy to influence food
prices,121,122although not as an end in itself but as part of
a much broader set of measures.Current evidence in this
respect is, however, fragmented and inconclusive,123,124
especially as far as low SES groups are concerned.125Fur-
thermore, in light of their complex nature, any alteration
to the price of a food affects both its consumption
(demand elasticity) and that of other foods (cross-
elasticity).126However, a study undertaken in the United
States that analyzed food prices and demand over a
correlated and that this correlation affects health vari-
ables.127In another theoretical study, Smith-Spangler
et al.128concluded that a salt-reduction program involv-
ing the food industry could reduce salt intake by 9.5%,
whereas a tax on Na decreases population sodium Na by
To date,the main focus of such fiscal policies is their
possible effect on obesity control,leading to the term“fat
that penalizes foods with a saturated fatty acid content of
thus favoring fruit and vegetables and organic pro-
ducts. Taxes on sugar-sweetened drinks have also been
increased in Norway and Latvia. However, none of these
countries are considering taxing foods and beverages
The case of a value added tax (VAT) on bread in
Spain is particularly paradoxical and has the opposite
effect to that discussed above. Thus, bread is subject to
two VAT rates: 1) the so-called super-reduced rate (4%),
which is applied to white bread, and 2) the reduced rate
(10%), which applies to special bread. Special bread in
Spain is any bread that contains anything other than
refined wheat flour,water,salt,yeast,and various allowed
additives. The paradox here is that healthier breads,
such as whole-meal bread, are classified as special and
therefore subject to a higher VAT rate than white bread.
Likewise,the possibility of replacing some of the salt with
a potassium salt would also be penalized fiscally, thus
making the product more expensive. A rapid review of
this tax for those breads that provide some type of nutri-
tion or health claim is consequently required.
Bread production in Europe is currently concentrated in
either the industrial sector or in more- or less-specialized
bakeries that produce specialty and more expensive
breads to supply the so-called niche market. In commer-
cial terms, bread is considered to be a high-volume, low-
cost, and low-margin product. It is clear that most bread
consumed is of the industrial type, including by the low
SES population;therefore,any action aimed at nutritional
improvement must take such bread into account. The
added value that translates into marked price increases is
less accessible to the consumers of basic products and,
therefore, has little significance in terms of community
According to Gellynck et al.129different population
clusters have different perceptions of bread quality, with
adverse perceptions such as “tasteless” and “unhealthy”
having a markedly negative effect on consumption. The
concept of “tasteless” can be resolved by improving the
industrial bread-making process to produce industrial
breads with better sensory characteristics, whereas the
concept of “unhealthy,” in this case referring to the salt
content, can be approached in four ways.
Adjustment to regional markets
As noted above, the variety of breads, and also their
demand, varies widely throughout Europe, and the
expected quality of these breads also varies depending on
the country in which the consumer lives. In the north of
Europe,for example,where bread tends to contain a high
proportion of crumb with one or more cereals, sour-
for sandwiches or toast, a gradual salt-reduction strategy
similar to that applied in the UK may be suitable.Indeed,
it has been shown that the perceived saltiness of bread
increases with acidity130and that, in Finland, the salt
content of sour rye bread is not a key factor in terms of
In contrast, in southern Europe, where crusty wheat
bread made using sponge-leavened dough predominates,
bread is used to accompany a meal and must therefore
have its own nature in terms of sensory characteristics.
In this case, it is likely that the salt content ought to be
reduced more gradually to ensure correct adaptation and
Nutrition Reviews® Vol. 70(11):666–678
that some type of sourdough adapted to the tastes of each
also be required. It should be noted that, in a study con-
ducted in France, consumers preferred baguettes with a
fermentation process than usually applied.106
However, a very wide range of bread varieties and
regional specialties, all of which should be treated indi-
vidually, exists between these two options.
Nutritional bread improvement
This option depends on bread makers and involves
reducing the sodium content and increasing the potas-
sium content,if necessary,with a minimum cost increase
and maintaining the sensory profile. To compromise the
taste of foods for health is a highly speculative and risky
Product communication and information
Food labeling is one of the most important sources of
nutritional information and,as noted above,reporting of
Na or salt content is now mandatory.31Apart from salt
nutrition or health claims, it is necessary to reinforce
communication with signposts or clarifying information
front of the food’s packaging.133,134The contribution of
making the existing point-of-purchase environment
more conducive to the selection of healthy choices is also
In 1992, Finland legally established salt content-
based food categories. Thus, in the case of bread, those
products with a salt content of more than 1.3% must be
labeled as “heavily salted,” whereas those with a salt
content of less than 0.7% can be labeled as“lightly salted.”
By 1998, a survey of Finnish supermarkets found that
only 0.9% of bread was heavily salted,whereas 92.5% was
normally salted (salt content of between 0.7% and 1.3%),
and 6.6% was lightly salted.136Apart from the above-
mentioned salt-reduction strategies in Finland,this label-
ing information is considered to have had a marked
impact on consumer choice.137In light of the importance
of labeling, it would be important to establish a Europe-
wide symbol to identify those products with a reduced
salt content, as based on pre-established limits, which, in
the case of bread, could be set to 1%.
One important point to consider here is the source of
information,i.e.,official information versus that found in
the media. The diffuse and often unreliable information
published by the mass media may provoke some degree
of consumer rejection of functional foods.138The support
of governments and institutions by way of clear messages
regarding the risks associated with high salt intake is,
therefore,vital.The use of distinctive symbols is also nec-
essary to identify bakery products with reduced or low
Na/salt content, and should be extended to the whole
range of manufactured products, especially meat-based
and dairy products, which, together with bread, provide
the most dietary Na.
ATHEORETICAL SALT-REDUCTION MODEL FOR BREAD
Presented here is a theoretical exercise regarding salt
reduction in baguette-type wheat bread with a water
content of 58% BR and a final water content of 28–30%
for the baked product.This type of bread,or variations of
it,is widely consumed in southern Europe.A reduction in
salt content of one-third, and replacement of it with
potassium salt (KCl or K-Cit), was considered (Table 4).
This percentage was chosen on the basis of the informa-
tion available regarding the percentage replacement that
was unlikely to affect the sensory characteristics.
The Na and K contents for the various breads,
together with the corresponding replacement percent-
ages,can also be found in Table 4,which clearly shows the
one-third decrease in Na content and the corresponding
increase in K content arising from their percentage in the
respective molecules.Legally speaking,both breads could
carry the nutritional claim of “reduced sodium” (<25%)
and would fall within the Food Standards Agency’s 2012
target range for sodium of <0.4%. The situation for K
replacement either with KCl or K-Cit could claim to
provide a “source of potassium” along with the corre-
sponding health claim,the last with the above-mentioned
nutritional benefits.Its Na:K ratio also decreases dramati-
cally from 7.8 to 1.8.
sium intake (in g/day) arising from consumption of this
Table 4 Bread recipe and composition after
substitution of NaCl by KCl or K-Citrate.
Source of measurement
NaCl content (% BR)
Potassium salt (% BR)
Na (g/100 g)a
NaCl (%) (Na x 2.54)
K (g/100 g)a
aUnpublished data available from the authors.
Abbreviation: BR, baker’s recipe.
Nutrition Reviews® Vol. 70(11):666–678
type of bread, in which a third of the salt is replaced
by KCl, for various European countries based on
their per capita consumption (Table 1). As can be seen
from this figure, this would represent a reduction in
total salt intake of between 0.6 and almost 1 g/day,
increasing to 2 g/day for Turkey. According to the latest
figures for Na in urine over 24 h (Table 3),these salt con-
centrations would represent a total reduction in salt
terms, the total Na/K intake ratio would drop from
around three to two.
There is currently a marked imbalance in Na and K
intakes in Europe and other developed countries, which
could lead to high rates of BP, CVD, and other diseases.
The available salt intake figures confirm a high level of
consumption (10 g/day), which urgently needs to be
reduced. It has been shown that small, consistent
general population, with an optimal cost/benefit ratio. It
would, therefore, be interesting to apply salt-reduction
strategies, such as those conducted in Finland and the
UK, which are based on informational campaigns,
agreements with the food industry, and changes in
nutritional labeling. The following aspects of bread
should be considered:
Bread is widely considered to be the foodstuff that
provides the most dietary salt (20–25%), and should,
therefore, be one of the key targets in any salt-reduction
Clear and consistent methodological criteria for
measuring the salt content in bread and for expressing
the results should be developed in order to decrease
A stepwise decrease in the salt content of bread is
possible, especially when starting from high values.
Another alternative is to partially replace salt by other
forms of salt, mainly of potassium, which also tend to
counteract the effect of sodium (decreasing the Na/K
Salt replacement should aim to maintain the food
product’s sensory profile.
The food industry should promote the production of
bread with enhanced flavor, by modifying either the
ingredients or the production processes, as this assists a
reduction in the salt content.
European legislation in the field of nutrition and
health claims allows the positive aspects of salt reduction
and/or replacement to be highlighted on food labels and
in marketing. Legislation is currently not the method of
choice for limiting the salt content of bread.
The application of taxes and subsidies to regulate salt
content is currently either not contemplated or is under
discussion in European countries. However, certain
aspects, such as current VAT in Spain, which penalizes
breads with enhanced nutritional characteristics, need to
Governmental public administrations should con-
tinue to promote active salt-reduction policies.
FranceItaly PortugalSpain Turkey
–5% –7.6% –6.2%
Figure 2 Changes in daily intake of NaCl (white) and K (black) due to consumption of bread reduced in salt and
enriched with KCl in several European countries.
Grey box: percent decrease in the amount of salt consumed daily in each country.
Nutrition Reviews® Vol. 70(11):666–678
1. Haaland R. Porridge and pot, bread and oven: food ways and symbolism in
Africa and Near East from the Neolithic to the present. Camb Archaeol J.
Brown IJ, Tzoulaki I, Candeias V, et al. Salt intakes around the world: implica-
tions for public health. Int J Epidemiol. 2009;38:791–813.
He FJ, MacGregor GA. A comprehensive review on salt and health and current
experience of worldwide salt reduction programmes. J Hum Hypertens.
Lindeberg S. Modern human physiology with respect to evolutionary adapta-
of Hominin Diets. Berlin: Springer; 2009:33–57.
Eaton SB, Eaton SB III. Paleolithic versus modern diets – selected pathophysi-
ological implications. Eur J Nutr. 2000;39:67–70.
Eaton SB, Eaton SB III, Konner MJ. Paleolithic nutrition revisited: a twelve-year
retrospective on its nature and implications. Eur J Clin Nutr. 1997;51:207–216.
Lev-Ran A, Porta M. Salt and hypertension: a phylogenetic perspective. Diabe-
tes Metab Res Rev. 2005;21:118–131.
physiologic effects of the post-agricultural inversion of the potassium-to-
sodium and base-to-chloride ratios in the human diet. Eur J Nutr. 2001;40:
Adeva MM, Souto G. Diet-induced metabolic acidosis. Clin Nutr. 2001;30:416–
Dewettinck K, Van Bockstaele F, Kühne B, et al. Nutritional value of bread:
influence on processing, food interaction and consumer perception. J Cereal
19 to 64 Years.Types and quantities of food consumed.TSO. 2002; Available at:
James WPT, Ralph A, Sanchez-Castillo CP. The dominance of salt in manufac-
tured food in the sodium intake of affluent societies. Lancet. 1987;329:426–
Mattes RD, Donnelly D. Relative contributions of dietary-sodium sources. J Am
Coll Nutr. 1991;10:383–393.
Joossens JV, Sasaki S, Kesteloot H. Bread as a source of salt – an international
comparison. J Am Coll Nutr. 1994;13:179–183.
Food Safety Authority of Ireland. Salt and Health: Review of the Scientific Evi-
dence and Recommendations for Public Policy in Ireland. Dublin: FSAI; 2005;
report-1.pdf. Accessed 12 October 2011.
Akpolat T, Kadi R, Utaş C. Hypertension, salt, and bread. Am J Kidney Dis.
intake inTurkish population: SALTURK study. Blood Press. 2010;19:313–318.
Vandevijvere S, De Keyzer W, Chapelle JP, et al. Estimate of total salt intake in
two regions of Belgium through analysis of sodium in 24-h urine samples. Eur
J Clin Nutr. 2010;64:1260–1265.
Meneton P, Jaunemaitre X, De Wardener HE, et al. Links between dietary salt
AESAN. Agencia Española de seguridad Alimentaria y Nutrición. Plan de reduc-
ción de sal. Jornadas de debate [in Spanish]. 2009; Available at: http://
Bates B, Lennox A, Swan G. National Diet and Nutrition Survey. Headline Results
from Year 1 of the Rolling Programme (2008/2009). Food Standards Agency –
Department of Health. 2010; Available at: http://www.actiononsalt.org.uk/
Docs/32209.pdf. Accessed 12 October 2011.
Booth DA, Thompson A, Shaedian B. A robust, brief measure of an individual’s
most preferred level of salt in an ordinary foodstuff. Appetite. 1983;4:301–312.
Conner MT, Booth DA, Clifton VJ, et al. Individualized optimization of the salt
content of white bread for acceptability. J Food Sci. 1988;53:549–554.
Sosa M, Flores A, Hough G, et al. Optimum level of salt in French-type bread.
Influence of income status, salt level in daily bread consumption, and test
location. J Food Sci. 2008;73(Suppl):S392–S397.
Booth DA, Conner MT. Salt in bread. J Food Sci. 2009;74:vii–viii.
Vieira E, Oliveira BMPM, Soares ME, et al. Estudo do teor de sódio em pão
consumido no Porto. Alimentação Humana. 2007;13:97–103.
as determined by flame photometry. Food Chem. 2009;113:621–628.
Observatoire du pain. Sel et pain. Renforcer la consummation de pain et réduire
celle de sel. 2008; Available at: http://www.observatoiredupain.fr/Images/
Produits/18F97720-E093-4A0C-8B95-1B179628E843.PDF. Accessed 7 October
29. MhurchuCN,CapelinC,DunfordEK,et al.Sodiumcontentofprocessedfoodsin
Am J Clin Nutr. 2011;93:594–600.
Egan MB, Fragodt A, Raats MM, et al. The importance of harmonizing food
composition data across Europe. Eur J Clin Nutr. 2007;61:813–821.
European Parliament and Council of the European Union. Regulation (EU)
1169/2011 of the European Parliament and of the Council of 25 October 2011
on the provision of food information to consumers. Available at: http://eur-
Accessed 21 September 2012.
Grassi G. Sympathetic neural activity in hypertension and related diseases. Am
J Hypertens. 2010;23:1052–1060.
Duprez DA. Role of the rennin-angiotensin-aldosterone system in vascular
remodelling and inflammation: a clinical review. J Hypertens. 2006;24:983–
Intersalt Cooperative Research Group. Intersalt: an international study of elec-
trolyte excretion and blood pressure. BMJ. 1988;297:319–328.
Laatikainen T, Pietinen P, Valsta L, et al. Sodium in the Finnish diet: 20-year
Du Cailar G, Mimran A, Fesler P, et al. Dietary sodium and pulse pressure in
normotensive and essential hypertensive subjects. J Hypertens. 2004;22:697–
Venezia A, Barba G, Russo O, et al. Dietary sodium intake in a sample of adult
male population in southern Italy: results of the Olivetti Heart Study. Eur J Clin
risk of cardiovascular events and all-cause mortality: the Rotterdam Study. Eur
J Epidemiol. 2007;22:763–770.
Polonia J, Maldonado J, Ramos R, et al. Estimation of salt intake by urinary
rial stiffness. Rev Port Cardiol. 2006;25:801–817.
Ribic CH, Zakotnik JM, Vertnik L, et al. Salt intake of the Slovene population
assessed by 24 h urinary excretion. Public Health Nutr. 2010;13:1803–1809.
24 h urinary sodium excretion in a representative sample of Spanish adults. Br
J Nutr. 2011;105:787–794.
Health Nutr. 2009;13:601–605.
and women: the Norfolk Cohort of the European Prospective Investigation to
Cancer (EPIC-Norfolk). Am J Clin Nutr. 2004;80:1397–1403.
Zhou BF, Stamler J, Dennis B, et al. for the INTERMAP Research Group. Nutrient
United States in the late 1990s: the INTERMAP study. J Hum Hypertens.
Available at: http://www.food.gov.uk/multimedia/pdfs/ndnsv3.pdf. Accessed
18 August 2011.
NCSR (National Centre for Social Research). An Assessment of Dietary Sodium
Available at: http://www.food.gov.uk/multimedia/pdfs/08sodiumreport.pdf.
Accessed 10 August 2011.
Elliot P, Stamler J, Nichols R, et al. Intersalt revisited: further analyses of 24 h
sodium excretion and blood pressure within and across populations. BMJ.
Hoffmann IS, Cubeddu LX. Salt and metabolic syndrome. Nutr Metab Cardio-
vasc Dis. 2009;19:123–128.
He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink consump-
US Department of Agriculture and US Department of Health and Human
Services. Dietary Guidelines for Americans. 2010; Available at: http://
15 September 2011.
Colhoun HM, Hemingway H, Poulter NR. Socio-economic status and blood
pressure: an overview analysis. J Hum Hypertens. 1998;12:91–110.
Saint-Elie DT, Patel PV, Healy KA, et al. The impact of income and education on
dietary habits in stone formers. Urology. 2010;76:307–313.
Purdy J, Armstrong G, McIlveen H. The influence of socio-economic status on
salt consumption in Northern Ireland. Int J Consum Stud. 2002;26:71–80.
Murakami K, Sasaki S, Takahashi Y, et al. Neighborhood socioeconomic disad-
vantage is associated with higher ratio of 24-h urinary sodium to potassium in
young Japanese women. J Am Diet Assoc. 2009;109:1606–1611.
Strazzullo P, D’Elia L, Kandala NB, et al. Salt intake, stroke, and cardiovascular
disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567.
Nutrition Reviews® Vol. 70(11):666–678
Sanders PW. Dietary salt intake, salt sensitivity, and cardiovascular health.
tens Rep. 2011;13:55–66.
Karppanen H. Minerals and blood pressure. Ann Med. 1991;23:299–305.
D’Elia L, Barba G, Cappuccio FP, et al. Potassium intake, stroke and cardiovas-
cular disease. A meta-analysis of prospective studies. J Am Coll Cardiol.
Van Mierlo LAJ, Greyling A, Zock PL, et al. Suboptimal potassium intake and
potential impact on population blood pressure. Arch Intern Med.
Vaskonen T. Dietary minerals and modification of cardiovascular risk factors. J
Nutr Biochem. 2003;14:492–506.
He FJ, Marciniack M, Carney C, et al. Effects of potassium chloride and potas-
turnover in mild hypertensives. Hypertension. 2010;55:681–688.
Berry SE, Mulla UZ, Chowienczyck PJ, et al. Increased potassium intake from
vascular function in UK men and women with early hypertension: a ran-
domised controlled trial. Br J Nutr. 2010;104:1839–1847.
Kotchen TA. Contributions of sodium and chloride to NaCl-induced hyperten-
sion. Hypertension. 2005;45:849–850.
Luft FC, Zemel MB, Sowers JA, et al. Sodium bicarbonate and sodium chloride:
sive man. J Hypertens. 1990;8:663–670.
Schorr U, Distler A, Sharma AM. Effect of sodium chloride- and sodium
elderly normotensive individuals: a randomized double-blind crossover trial.
J Hypertens. 1996;14:131–135.
Overlack A, Maus B, Ruppert M, et al. Potassium citrate versus potassium chlo-
ride in essential hypertension. Effects on haemodynamic, hormonal and meta-
bolical parameters. Dtsch MedWochenschr. 1995;120:621–635.
He FJ, Markandu ND, Coltart R, et al. Effect of short term supplementation of
potassium chloride and potassium citrate on blood pressure in hypertensives.
Braschi A, Naismith DJ. The effect of dietary supplement of potassium chloride
or potassium citrate on blood pressure in predominantly normotensive volun-
teers. Br J Nutr. 2008;99:1284–1292.
Sellmeyer DE, Schloetter M, Sebastian A. Potassium citrate prevents increased
diet. J Clin Endocrinol Metab. 2002;87:2008–2012.
Demigne C, Sabboh H, Remesy C, et al. Protective effects of high dietary
potassium: nutritional and metabolical aspects. J Nutr. 2004;134:2903–
diet with potassium citrate increases bone mass in postmenopausal women
with osteopenia. J Am Soc Nephrol. 2006;17:3213–3222.
rennin, aldosterone, catecholamines, cholesterols and triglyceride. JAMA.
He FJ, MacGregor GA. How far should salt intake be reduced? Hypertension.
dietary approaches to lower blood pressure. J Am Soc Hypertens. 2009;3:321–
Selmer RM, Kristiansen IS, Haglerød A, et al. Cost and health consequences of
reducing the population intake of salt. J Epidemiol Community Health.
Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary
salt reductions on future cardiovascular disease. N Engl J Med. 2010;362:590–
Geleijnse JM, Kok FJ, Grobbee DE. Blood pressure response to changes in
sodium and potassium intake: a metaregression analysis of randomised trials.
J Hum Hypertens. 2003;17:471–480.
Cook NR, Obarzanek E, Cutler JA, et al. Joint effects of sodium and potassium
tion (TOHP) follow-up study. Arch Intern Med. 2009;169:32–40.
Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc
Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations
revision 2006. Circulation. 2006;114:82–96.
Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the manage-
ment of arterial hypertension. The task force for the management of
arterial hypertension of the European Society of Hypertension (ESH) and
the European Society of Cardiology (ESC). J Hypertens. 2007;25:1105–
84. Karppanen H, Karppanen P, Mervaala E. Why and how to implement sodium,
potassium, calcium and magnesium changes in food items and diets? J Hum
alters taste of salt. Am J Clin Nutr. 1982;36:1134–1144.
Girgis S, Neal B, Prescott J, et al. A one-quarter reduction in the salt content of
bread can be made without detection. Eur J Clin Nutr. 2003;57:616–620.
Consumer's Food Choice during Breakfast. Proc 4thEuropean Conference on
Sensory and Consumer Research. Vitoria (Spain). 2010; Available at: http://
pdf. Accessed 11 October 2011.
Miller RA, Hoseney RC. Role of salt in baking. Cereal FoodsWorld. 2008;53:4–6.
Quilez J, Ruiz JA, Romero MP. Relationships between sensory flavor evaluation
and volatile and nonvolatile compounds in commercial wheat bread type
baguette. J Food Sci. 2006;71(Suppl):S423–S427.
Lynch EJ, Dal Bello F, Sheenan EM, et al. Fundamental studies on the reduction
of salt on dough and bread characteristics. Food Res Intern. 2009;42:885–891.
Crit Rev Food Sci Nutr. 2012;52:514–524.
Noort WJ, Bult JHF, Stieger M, et al. Saltiness enhancement in bread by homo-
geneous spatial distribution of sodium chloride. J Cereal Sci. 2010;52:378–386.
Salovaara H. Effect of partial sodium chloride replacement by other salts on
wheat dough rheology and breadmaking. Cereal Chem. 1982;59:422–426.
Kaur A, Bala R, Singh B, et al. Effect of replacement of sodium chloride with
mineral salts on rheological characteristics of wheat flour. Am J Food Technol.
J Food Sci. 1982;47:672–673.
magnesium in bread. Cereal Chem. 1982;59:427–430.
Takano H, Kondou R. Sodium gluconate and potassium gluconate as substi-
tutes of sodium chloride in breadmaking. Food SciTechnol Res. 2002;8:75–79.
Salovaara H, Helleman U, Kurkela R. Effect of salt on bread flavour. Lebensm
Charlton KE, MacGregor E, Vorster NH, et al. Partial replacement of NaCl can be
achieved with potassium, magnesium and calcium salts in brown bread. Int J
Food Sci Nutr. 2007;58:508–521.
Braschi A, Gill L, Naismith DJ. Partial substitution of sodium with potassium in
Stroh M, Setser CS, Bruinsma B, et al. Sensory interactions of formulations to
mask potassium chloride flavor using Morton lite salt mixture in white pan
breads. Cereal Chem. 1985;62:103–107.
Gyu-Hee L. A salt substitute with low sodium content from plant aqueous
extracts. Food Res Intern. 2011;44:537–543.
Toldra F, Barat JM. Recent patents for sodium reduction in foods. Recent Pat
Food Nutr Agric. 2009;1:80–86.
Council of the European Union. Council Conclusions on Action to Reduce Popu-
lation Salt Intake for Better Health. 2010; Available at: http://www.
Accessed 20 October 2011.
Food Standards Agency. 2010–2012 Salt Reduction Targets. 2009; Available at:
http://www.food.gov.uk/news/newsarchive/2009/may/salttargets. Accessed 2
Agence Française de Sécurité Sanitaire. Report on Salt: Evaluation and Recom-
mendations. 2002; Available at: http://www.anses.fr/Documents/NUT-Ra-
Sel.pdf. Accessed 28 September 2011.
prevention of obesity. Br J Nutr. 2006;96(Suppl 1):S8–S11.
Arrêté Royal 1976030801 Portant Limitation de la Teneur en Sel Dans le Pain de 8
de Mars 1976. [in French]. Available at: http://www.ejustice.just.fgov.be/
Accessed 21 September 2012.
Lei 75/2009 de 12 de Agosto. Estabelece Normas com Vista à Redução do Teor de
Sal No Pão Bem Como Informação na Rotulagem de Alimentos Embalados Desti-
nados ao Consumo Humano. [in Portuguese]. Diário da República. 2009;155:
Martins L, Nazare J, Pinto F, et al. Portuguese action against salt and hyperten-
content. J Hypertens. 2009;27(Suppl):S326.
2006 of the European Parliament and of the Council of 20 December 2006 on
Nutrition and Health Claims Made on Foods. Available at: http://eur-
EN:PDF. Accessed 21 September 2012.
European Commission. Health and Consumers Directorate-General. Working
document on the setting of nutrient profiles. 2008; Available at: http://
www.food.gov.uk/multimedia/pdfs/consultation/ecsettingnp.pdf. Accessed 5
Nutrition Reviews® Vol. 70(11):666–678
113. EuropeanParliamentandCounciloftheEuropeanUnion.Regulation(EC)1925/ Download full-text
2006 of the European Parliament and of the Council of 20 December 2006 on the
404:0026:0038:EN:PDF. Accessed 21 September 2012.
Commission of the European Communities. Commission Directive 2008/100/EC
for Foodstuffs as Regards Recommended Daily Allowances, Energy Conversion
Factors and Definitions. Available at: http://eur-lex.europa.eu/LexUriServ/
LexUriServ.do?uri=OJ:L:2008:285:0009:0012:EN:PDF. Accessed 21 September
European Commission. Commission Regulation (EU) 432/2012 of 16 May 2012
Referring to the Reduction of Disease Risk and to Children’s Development and
Health. Availableat: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?
uri=OJ:L:2012:136:0001:0040:en:PDF. Accessed 21 September 2012.
European Food Safety Authority. Opinion of the scientific panel on dietetic
products, nutrition and allergies on a request from the Commission related to
the tolerable upper intake level of chloride. EFSA J. 2005;193:1–9.
Food and Nutrition Board. Dietary Reference Intakes for Water, Potassium,
Sodium, Chloride and Sulfate. Institute of Medicine. Washington, DC: National
Academic of Sciences; 2004; Available at: http://www.nal.usda.gov/fnic/DRI//
DRI_Water/water_full_report.pdf. Accessed 22 September 2011.
Suggs S, McIntyre C. European Union public opinion on policy measures to
address childhood overweight and obesity. J Public Health Policy. 2011;32:91–
FoodDrink Europe. FDE Rebukes Discriminatory Tax on Soft Drinks in France.
2011; Availableat: http://www.fooddrinkeurope.eu/news/statement/
a/. Accessed 11 October 2011.
Thow AM, Jan S, Leeder S, et al. The effect of fiscal policy on diet, obesity and
chronic disease: a systematic review. Bull World Health Organ. 2010;88:609–
Geneva: WHO; 2004.
Prevention and Control of Noncommunicable Diseases. Geneva:WHO; 2008.
123. Caraher M, Cowburn G. Taxing food: implications for public health nutrition.
Public Health Nutr. 2005;8:1242–1249.
Cash SB, Lacanilao RD. Taxing food to improve health: economic evidence and
arguments. Agric Resour Econ Rev. 2007;36:174–182.
Nnoham KE, Sacks G, Rayner M, et al. Modelling income group differences in
the health and economic impacts of targeted food taxes and subsidies. Int J
Mytton O, Gray A, Rayner M, et al. Could targeted food taxes improve health?
J Epidemiol Community Health. 2007;61:689–694.
Duffey KJ, Gordon-Larsen P, Shikany JM, et al. Food price and diet and health
outcomes. 20 years of CARDIA study. Arch Intern Med. 2010;170:420–426.
sodium intake and the burden of cardiovascular disease. A cost-effectiveness
analysis. Ann Intern Med. 2010;152:481–487.
Gellynck X, Kühne B, Van Bockstaele F, et al. Consumer perception of bread
quality. Appetite. 2009;53:16–23.
J Food SciTechnol. 1992;27:201–211.
Heiniö RL, Urala N, Vainionpää J, et al. Identity and overall acceptance of two
types of sour rye bread. Int J Food SciTechnol. 1997;32:169–178.
Verbecke W. Functional foods: consumer willingness to compromise on taste
for health? Food Qual Prefer. 2006;17:126–131.
Grunert KG, Wills JM. A review of European research on consumer response to
nutrition information on food labels. J Public Health. 2007;15:385–399.
Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a
systematic review. Public Health Nutr. 2011;14:1496–1506.
a systematic review. Public Health Nutr. 2005;8:21–28.
Närhinen M, Nissinen A, Pentillä PL, et al. Salt content labelling of foods in
supermarkets in Finland. Agric Food Sci Finl. 1998;7:447–453.
Pietinen P, Valsta LM, Hirvonen T, et al. Labelling the salt content in foods: a
useful tool in reducing sodium intake in Finland. Public Health Nutr.
Verbecke W. Impact of communication on consumers’ choices. Proc Nutr Soc.
Nutrition Reviews® Vol. 70(11):666–678