title: State-level and community-level salt reduction initiatives: a systematic review of global programmes and their impact.
abstract: High-salt diets are linked to elevated blood pressure, a major risk factor for cardiovascular diseases, particularly stroke. State and community salt reduction strategies may complement nationally led initiatives and contribute to achieving global salt reduction targets. We aim to systematically review such interventions and document reported impact where programmes have been evaluated.
  
  
  
  Electronic databases were searched up to June 2015 using terms 'salt' or 'sodium' and 'state' and 'community' in combination with 'campaign', 'initiative', 'project', 'strategy', 'intervention' or 'programme'. Data from evaluated and unevaluated interventions were included. Studies were analysed in relation to intervention components and outcome measures and appraised for quality using a Cochrane Risk-of-Bias Tool.
  
  
  
  39 state and community programmes were identified. Settings varied from whole communities (n=23), state-owned buildings (n=5), schools (n=7), workplaces (n=3) and correctional facilities (n=1). Strategies included nutrition education programmes, public education campaigns, changes to the food environment, other 'novel' approaches and multifaceted approaches. Of the 28 studies that evaluated intervention effectiveness, significant reductions were observed in terms of salt intake from dietary assessment (n=7), urinary sodium excretion (n=8), blood pressure (n=11) and sodium in foods (n=9). Six studies reported positive changes in consumer knowledge, attitudes and behaviours. All but two studies had some methodological limitations.
  
  
  
  State and community salt reduction programmes may be effective in a range of settings but more robust evaluation methods are needed. Scaling up these efforts in coordination with national initiatives could provide the most effective and sustainable approach to reducing population salt intake.
authors.affiliation: Food Policy Division, The George Institute for Global Health (affiliated with the University of Sydney), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: Anthea
authors.initials: A
authors.lastname: Christoforou
authors.affiliation: Food Policy Division, The George Institute for Global Health (affiliated with the University of Sydney), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: Kathy
authors.initials: K
authors.lastname: Trieu
authors.affiliation: Food Policy Division, The George Institute for Global Health (affiliated with the University of Sydney), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: Mary-Anne
authors.initials: MA
authors.lastname: Land
authors.affiliation: The Victorian Health Promotion Foundation (VicHealth), Carlton, Victoria, Australia.
authors.forename: Bruce
authors.initials: B
authors.lastname: Bolam
authors.affiliation: Food Policy Division, The George Institute for Global Health (affiliated with the University of Sydney), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
authors.forename: Jacqui
authors.initials: J
authors.lastname: Webster
mesh_terms: D004039:Diet, Sodium-Restricted; D014943:Global Health; D006293:Health Promotion; D006801:Humans; D006973:Hypertension / Q000517:prevention & control*; D017673:Sodium Chloride, Dietary / Q000008:administration & dosage*
chemical_list: D017673:Sodium Chloride, Dietary
keywords: Cardiovascular disease; PUBLIC HEALTH; SYSTEMATIC REVIEWS