Population-wide Reduction of Salt Intake
Discuss about the Global Health and Sustainable Development.
Reduction of salt intake is linked to lower levels of blood pressure and reduction in the risk of cardiovascular disease. Hypertension is a global health problem and it increases the risk of cardiovascular disease. Prevention of chronic diseases is a public health priority, it is important to aim at reducing salt intake, particularly since there is evidence that it reduces diastolic and systolic blood pressure (He, Li, & Macgregor, 2013). The public burden of cardiovascular disease can be reduced and a reduction in health care costs are the benefits derived from population-wide reduced sodium intake (Cobb, Appel, & Anderson, 2012). In the developing world, the fiscal challenges leave little to cope with the increasing expenditures on healthcare. Interventions that reduce the incidence hypertension, or that can control and prevent associated chronic diseases through health education have been recognised as an important step towards reducing inequities in delivery of healthcare (Livingston, 1985). The importance of an initiative is underlined in settings where non-adherence to a low-salt diet is common and hypertension remains uncontrolled (Shima, Farizah, & Majid, 2014). 49% of coronary heart disease and 62% of strokes occur due to hypertension and a reduction in salt intake can reduce the disease burden to a considerable extent. Reduction in salt intake can be brought about through reduction in added salt in processed food that accounts for 75% of the salt intake in Western diets. Additionally, educating people about reduced addition of salt to home-cooked food can help reduce the consumption of salt and reach closer to the target of consuming less salt (3 g/d) as per the WHO recommendation (WHO, 2012; He & McGregor, A comprehensive review on salt and health and current experience of worldwide salt reduction programmes., 2009). In economic terms the benefit of a reduced salt diet by 3g/d and the concomitant reduction in blood pressure can save upto $24 billion in healthcare costs each year, according to a Portuguese study. A saving of 392,000 quality adjusted life years and a drop of 92000 deaths every year are benefits that emphasize the importance of reduction in salt intake (Bibbins-Domingo, et al., 2010). Historically, man consumed as less as 0.25g of salt per day. But with its use in preservation the use increased and though the advent of refrigeration caused some reduction, the use of salt is still as high as 9 – 12 g/day. Governments of countries such as, Japan and Finland have run public health campaigns to reduce salt intake (He & McGregor, A comprehensive review on salt and health and current experience of worldwide salt reduction programmes., 2009). The INTERSALT study established a link between increased sodium intake, measured by urinary sodium excretion per day and increase in systolic blood pressure with age (Group, 1988). Another study, the INTERMAP study compared salt intake and several other micro- and macronutrient intake of participants from China, Japan, UK and USA. The sodium intake was found to be higher among the Asians than their western counterparts (Zhou, et al., 2003). Although current targets for salt reduction are 5-6g/d from the current 9-12g/d of salt, a drop to the WHO recommended levels of 3g/d would be ideally suited for maintenance of blood pressure in the normotensive range. Salt reduction initiatives and programs have been started in many countries around the world (Webster, Dunford, Hawkes, & Neal, 2011).
Initiatives and Programs for Salt Reduction
The UK Food Standards Agency (FSA) ran a salt reduction program from the year 2003 to 2010. The Scientific Advisory Committee on Nutrition that advised the government on issues related to nutrition in the UK recommended reduce salt intake to prevent morbidity and mortality due to cardiovascular disease. It was estimated that 6% deaths due to coronary heart disease could be reduced if the number of hypertensive persons could be reduced by 50%. If the mean diastolic blood pressure could be lowered by just 2 mmHg, a 15% drop in the incidence of stroke and transient ischemic attack can occur. A 6% drop in coronary heart disease would be another positive outcome. From the then average consumption of 9.5 g/d of salt consumption, a target level of 6 g/d was determined (Wyness, Butriss, & Stanner, 2011). Rather than the 3 g/d recommended consumption by WHO, the 6g/d target was considered to be more achievable at the population level (WHO, 2012). The key inputs to the programme involved the UK food industry that was asked to reduce salt content in their formulations of processed food. They were also asked to change the nutrition labels to formats that could be easily understood by the consumers. Consumer awareness campaigns for a low salt intake and raising consumer demand foe low salt containing foods was also part of the initiative. But the current salt consumption in UK has only dropped to 8.1 to 8.8 g/d. The target of 6 g/d is still distant (Food.gov.uk, 2017).
Food industry was given targets to achieve for reduced salt content in their processed food products. While some players were able to exceed targets, others had problems due to technical reasons and acceptability issues from consumers. The FSA continued with their engagement with the food industry and in 2012 new targets were given to the producers. An environment to continuous efforts towards reducing the salt content further has been an achievement.
Front of pack labelling encouraged by the FSA in addition to nutrition information also provides information on how healthy a food item is. Consumer behaviour in supermarkets is influenced when they choose foods labelled as healthy than foods that are less healthy. Indirectly, the food industry was also encouraged to label their foods with guideline daily amount (GDA) of nutrients. Traffic light colour coding helped consumers to choose foods that had more greens (low) than ambers (high).
Consumer awareness campaigns formed an important part of the salt reduction programme. Print media, television, radio, digital media and the government website were used to relay information about the need to reduce salt intake. Hard to reach sections of the population, such as, certain ethnic minorities were taken to grocery shop tours, cooking shows and taught how to choose foods and read labels so that salt intake would remain low. Awareness campaigns called ‘Sid the slug’, ‘Talking food’ and ‘Full of it’ tackled different aspects and spread the word about reducing salt intake among consumers.
Challenges Faced by the Food Industry
The food service sector, though not part of the initiative was also engaged and catering services, restaurants and sandwich outlets were also part of the reduced salt initiative and were educated on how to reduce addition of salt. The multi-pronged approach helped to reach the goal of reducing salt intake by the UK population.
The first barrier that the food industry faced when lowering salt in processed food, was concern regarding the microbiological safety of food, meat products in particular were said to be at a higher risk of spoilage. Because salt reduces the availability of water it can either kill microorganisms or reduce their growth. Other additives were proposed and reformulated food were assessed to be safe even with lower salt content. Another barrier was consumer acceptance of foods with reduced salt. Two approaches were suggested to mitigate this problem. If reductions in salt were made gradually over a period of time rather than at once, consumers were able to accept the change more readily. Besides, the use of lesser salt is a behaviour change that consumer palates are still adjusting to, an 8 week period is required to accept low salt content. In certain foods like bread and cheese, the addition of salt is technically intrinsic to the fermentation process and separation of whey. In such cases, the FSA has allowed for a longer time period for the resolution and has supported the industry with research projects that are working towards the development of low salt breads and low salt cheese. This creates an enabling environment for stakeholders in the food industry and ensures that their participation in the intervention will remain constructive. There has been evidence of voluntary salt reduction by food industry. The consumer awareness program needs to teach people to monitor their own salt intake through careful reading of nutrition labels on packaged food and reduce addition of salt to home cooked food (Xuereb, 2013).
In order to provide equitable outreach to all sections of the population, special programs for campaign effectiveness among the ethnic minorities are necessary. Public education through campaigns is effective and relatively cheap. But it has to be coupled with the availability of low sodium containing food. Dietary counselling by physicians and healthcare professionals can help in disseminating information about the need to reduce sodium intake. Apart from reading labels advice about eating fresh foods rather than processed food, avoiding seasonings that contain sodium, choosing foods with less sodium, are steps that are easy to follow (Cobb, Appel, & Anderson, 2012).
Consumer Acceptance and Behaviour Change
Efforts to influence consumer behaviour and reduce salt intake have to be made in an environment that is conducive to change. Creating such an environment is possible when all the stakeholders including the regulatory bodies, policy makers, food industry, consumers and health professionals are highly motivated by a strong leadership and appropriate funding. Behaviour change of consumers and keeping their motivation to reduce salt intake are important factors in reaching the goal. Understanding nutrition labels and quickly calculating the general dietary allowance calls for numeracy, that many consumers find difficult when shopping in a supermarket. Making a quick assessment of salt intake through nutrition labels is difficult for informed and motivated consumers. Public awareness programs should focus on increasing consumer education through various media (McLean & Hoek, 2014).
Implementation of the initiative should focus on increasing public awareness. Some consumers may have understood the need to reduce salt intake. But there are many who have not understood the link between salt intake and health. There are difficulties in understanding food labels and assessment of their understanding is important in order to fill gaps with easy to understand campaign material (Cowburn & Stockley, 2004). An Australian study found that consumers did not have the ability to understand labels that mentioned salt and/or sodium, although 88% of the study participants were aware that high salt intake is linked to hypertension. Nutrition labelling should follow consistent methods of labelling (Grimes, Riddell, & Nowson, 2009).
A qualitative study design to assess consumer understanding of the need to reduce salt intake and their understanding of nutrition labels needs to be assessed.
Questionnaire for qualitative study design to assess consumer knowledge about how to read and interpret nutrition labels:
- What influences your decision to buy a particular food product when grocery shopping and do you think it is better to consume fresh food or processed food?
- Do you read nutrition information printed on the food package when purchasing food?
- Would you select foods with more green or more amber signs?
- How do you find the amount of salt in the food?
- What is the guideline daily allowance for salt in the UK?
- Why is it important to read the salt content of a food?
- Is the sodium content of food related to salt content?
- What could be the consequence if you consumed more salt than is recommended?
- Which foods would you choose to minimise the salt intake?
- Which nutrient labelling format do you understand?
- Does it help while selecting food with front of pack labels about fat, saturates, sugar and salt?
- Does it help to have labels in the form of traffic light colour coding on food packages?
The questionnaire can be given to consumers to assess their knowledge and engagement with the subject of reducing salt intake.
The questionnaire would be given to persons who do most of the grocery shopping for the household. The whole family consumes the foods purchased by one or two people. Some family members or the buyers themselves could be suffering from hypertension. In such a case, it will be interesting to learn more about the attitude of the buyer towards the salt content in the food. The salt restrictions are recommended to be followed by the children, and the normotensive members of the family.
Dissemination of the outcome of the qualitative study is important because it will be useful in addressing the shortcomings in the understanding of consumers regarding nutrition labelling. The main findings of the study are usually mentioned in a bullet point format on the first page. Policy makers can use it as a quick reference guide when formulating a policy change. These are the main implications of the evaluation of the proposed initiative. The following three pages should concisely describe the findings of the qualitative study. A detailed high quality report should follow and must include the analysis of the study and give recommendations. Other formats that can be used to disseminate information about the study on consumer understanding could be papers published in journals. This would allow the academic community to access the findings (Health.vic.gov.au, 2011).
References
Bibbins-Domingo, K. C.-D., Chertow, G. M., Coxson, P., Moran, A. E., Lightwood, J. M., Pletcher, M. J., & Goldman, L. (2010). Reductions in Cardiovascular Disease Projected from Modest Reductions in Dietary Salt. The New England Journal of Medicine, 362(7):590-599. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066566/
Cobb, L. K., Appel, L. J., & Anderson, C. A. (2012). Strategies to Reduce Dietary Sodium Intake. Current Treatment Options in Cardiovascular Medicine, 14(4): 425–434. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612540/
Cowburn, G., & Stockley, L. (2004). Consumer understanding and use of nutrition labelling:. Public Health Nutrition , 8(1): 21–28.
https://www.researchgate.net/profile/Gill_Cowburn/publication/8028200_Consumer_understanding_and_use_of_nutrition_labelling_A_systematic_review/links/0c9605278c3630eab3000000.pdf
Food.gov.uk. (2017). /salt. Retrieved from https://www.food.gov.uk: https://www.food.gov.uk/business-guidance/salt
Grimes, C., Riddell, L., & Nowson, C. (2009). Consumer knowledge and attitudes to salt intake and labelled salt information. Appetite, 53(2):189-194.
https://www.sciencedirect.com/science/article/pii/S019566630900542X
Group, I. C. (1988). Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. . BMJ?: British Medical Journal, 297(6644), 319–328.https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/3416162/
He, F., & McGregor, G. (2009). A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. Journal of human hypertension, 23(6):363-84.https://www.nature.com/articles/jhh2008144
He, F., Li, J., & Macgregor, G. (2013). Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ, 346:f1325. doi: 10.1136/bmj.f1325.https://www.bmj.com/content/346/bmj.f1325.long
Health.vic.gov.au. (2011). Evaluation-framework-for-health-promotion-and-disease-prevention-programs. Retrieved from https://www2.health.vic.gov.au/: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Evaluation-framework-for-health-promotion-and-disease-prevention-programs
Livingston, I. L. (1985). Hypertension and Health Education Intervention in the Caribbean: A Public Health Appraisal. . Journal of the National Medical Association, 77(4):273–280.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2561854/
McLean, R., & Hoek, J. (2014). Sodium and nutrition labelling: a qualitative study exploring New Zealand consumers’ food purchasing behaviours. Public Health NutritionVolume 17 Issue 5, 17(5):1138-1146.
https://www.cambridge.org/core/journals/public-health-nutrition/article/sodium-and-nutrition-labelling-a-qualitative-study-exploring-new-zealand-consumers-food-purchasing-behaviours/1EBB949FA607652810E2F4C98E721798/core-reader
Shima, R., Farizah, M. H., & Majid, H. A. (2014). A qualitative study on hypertensive care behavior in primary health care settings in Malaysia. Patient Preference and Adherence, 8: 1597–1609.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240212/
Webster, J., Dunford, E., Hawkes, C., & Neal, B. (2011). Salt reduction initiatives around the world. Journal of hypertension, 29(6):1043-50.
WHO. (2012). sodium_intake_printversion.pdf. Retrieved from https://www.who.int/: https://www.who.int/nutrition/publications/guidelines/sodium_intake_printversion.pdf
Wyness, L., Butriss, J., & Stanner, S. (2011). Reducing the population’s sodium intake: the UK Food. Public Health Nutrition, 15(2): 254–261 .
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Xuereb, G. (2013). SRP_2013_Godfrey_Xuereb_WHO.pdf. Retrieved from https://www.fsai.ie: https://www.fsai.ie/uploadedFiles/Science_and_Health/Salt_and_Health/SRP_2013_Godfrey_Xuereb_WHO.pdf
Zhou, B., Stamler, J., Dennis, B., Moag-Stahlberg, A., Okuda, N., Robertson, C., . . . Group, I. R. (2003). Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study. Journal of human hypertension, 17(9):623-30.
https://www.ncbi.nlm.nih.gov/pubmed/13679952
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