A Savory Approach to Reducing Sodium: What the United States Can Learn from South Africa’s Food Regulation

Alexandra Ross, PhD, MHS  

---

High sodium intake is associated with hypertension, heart disease, and strokes, making it a public health concern across the globe. However, reducing sodium consumption can be challenging due to the high levels present in packaged foods. Recognizing this public health concern, South Africa tackled this issue head-on by passing sodium reduction regulations—and the United States has proposed their own targets on a voluntary basis. So, what can we learn from South Africa’s approach?

The South African National Health and Nutrition Examination Survey previously reported that approximately one-third of adults over the age of 15 experience hypertension. To address this issue, South Africa introduced mandatory sodium reduction targets in 2013, requiring food manufacturers to progressively lower sodium levels in key processed food categories, such as processed meats, soup powders, breads, condiments, and ready to eat savory snacks.  Colleagues found changes have been associated with reductions in blood pressure measurements.
 
To evaluate the effects of these regulations, in a brief study with my South African colleagues, we analyzed sodium intake changes in a low-income township. We compared sodium levels in foods reported in 24-hour dietary recalls before and after the regulations took effect, using updated food composition tables.
 
We found that sodium levels across multiple food groups were lower due to changes at the manufacturing level (reformulation), especially in salami meats, soup from powder mixes, nuts and seeds, and breakfast cereals. Additionally, mean sodium intake declined, with the most pronounced reductions being among high consumers (those exceeding World Health Organization’s 2000 mg/day recommendation).
 
Our study showed that reformulation of products alone can reduce sodium intake in popular foods people already consume. In reality, healthy dietary changes are even more significant when combined with education and policy awareness. Public discussions around sodium reduction can help shape consumer choices, reinforcing the idea that healthier options were available and beneficial. This highlights the importance of pairing regulatory efforts with public health campaigns to support lasting behavior change.
 
Lessons for the United States
As the FDA considers sodium reduction targets, South Africa’s experience demonstrates that regulatory interventions can successfully decrease sodium consumption. Given the challenges of individual behavior change in dietary habits, reformulation of processed foods offers a pragmatic approach to improving population health without requiring significant effort from consumers. However, complementary public health strategies are essential for maximizing the impact, such as:

• Develop public education campaigns to increase awareness of sodium’s health risks and promote acceptance of lower-sodium foods. For example, bread is not considered a high sodium food but is the largest contributor of added sodium in the diet among South Africans. Understanding the food categories where most sodium consumption comes from can guide behaviors and education.
• Consider cultural acceptability of the reduced targets. South Africa had higher thresholds for specific foods, like salt-and-vinegar crisps – a favorite among South Africans – to improve public acceptance. All other crisp flavors were subject to the lower sodium regulations. 
• Create clear front-of-package labeling to facilitate informed consumer choices. South Africa is implementing a multi-level packaging system to help keep consumers informed about the foods they are purchasing.
• Provide industry incentives and regulation enforcements to ensure consistent and widespread compliance. South Africa’s target reductions have been considered successful due to its mandatory implementation.
• Implement policies for restaurants to encourage sodium reduction beyond packaged foods. A concern is that consumers might compensate for lower sodium levels in processed foods by adding table salt or consuming more restaurant-prepared meals.

 
Conclusion
South Africa’s experience underscores that sodium reduction policies can lower dietary sodium intake and reduce chronic disease risk. However, these efforts must be supported by consumer education, enforcement, transparent labeling, and equitable food access initiatives. By learning from South Africa’s successes and challenges, the U.S. can adopt a powerful, nationwide sodium reduction strategy to improve public health outcomes – and guilt-free snacking!

Author
​Alexandra Ross is interested in policy-level interventions to improve food accessibility, particularly as it relates to food pricing and nutrition assistance programs. Her goal is to do research that will develop and evaluate programmatic strategies to improve the availability, financial accessibility, and desirability of foods to improve diet quality and subsequent chronic disease risk. Her previous work focuses on changes in the retail food environment, emphasizing food pricing, nutrient regulations, and international policy evaluations in the United States and South Africa. Dr. Ross earned her PhD in Nutrition Epidemiology from the University of North Carolina Gillings School of Global Public Health and an MHS in Social Factors in Health from the Johns Hopkins Bloomberg School of Public Health.