Appendices and Acknowledgements
- Packaged foods
- Food prepared outside the home
- Sodium added in the home
- Appendices & Acknowledgments
- 20 Appendix 1. Sodium reduction program checklist
- 21 Appendix 2. Example content of a situational analysis for preparing a sodium reduction strategy
- 22 Appendix 3. Instructions for developing a food database
- 23 Acknowledgements
Appendix 1. Sodium reduction program checklist
Appendix 2. Example content of a situational analysis for preparing a sodium reduction strategy
The WHO describes a situational analysis as “an assessment of the current health situation...fundamental to designing and updating national policies, strategies and plans.”
An in-depth description of how to conduct a situational analysis for a national health policy is described in the WHO Situation Analysis in the Health Sector and includes a list of the stakeholders who should be involved, key characteristics of the analysis, links to tools for conducting an analysis, and a sample outline of a report. A participatory approach, which includes making information available to citizens and representatives from sectors that intersect with health, can enhance transparency and accountability. The analysis should assess not only the context for reducing population sodium intake, but the underlying causes, such as the social determinants of health, that have contributed to high sodium intake. It can also include a description of stakeholder roles and responsibilities, to understand which organizations hold formal and informal power.
The situational analysis may include answering the following types of questions to assess the strengths, weaknesses, opportunities, and threats to creating a national sodium reduction strategy:
Political support and opposition:
- What level of support and opposition to reducing dietary sodium exists at multiple levels (political, food industry, general public, health and scientific community) and how is this support expected to change over time?
- What are the expected economic and health advantages of a sodium reduction program?
- Are current policies to minimize financial conflicts of interest adequate?
- Is there likely to be organized opposition from individual companies, food industry groups or other organizations?
- Are there strong platforms to monitor food and salt industry influence (e.g., consumer protection groups)?
Monitoring and Evaluation:
- What data has already been collected on sodium intake, sources, or content in foods?
- How do levels of sodium intake and sources of sodium vary by geography, age, ethnicity, gender, or for other subgroups?
- What surveys, research and laboratory services are available to estimate overall sodium intake, the major dietary sources of sodium and the sodium levels of key foods and what steps need to be taken to fill any gaps?
- What is the perception of the general public on the main sources of sodium in the diet, the health impact of consuming too much sodium, and the importance of reducing sodium intake?
- What financial and other resources are available or likely to be obtained?
- What are the program needs that can be filled by key stakeholders and collaborators (e.g., education and advocacy, research, monitoring and evaluation, technical skills without conflicts of interest in reducing sodium content of foods)? This should include a stakeholder mapping exercise.
- What healthy food policies are already in place/planned; do they or can they integrate sodium reduction directly (e.g., sodium targets for foods) or indirectly (e.g., healthy public food procurement)?
- What regional and international legal frameworks could help/hinder the promotion and implementation of sodium reduction policies?
- Are there any current communication campaigns, by public health agencies or food companies, about nutrition and health or sodium intake specifically?
- How can critical groups, such as the household food purchaser/preparer, and vulnerable groups (e.g., ethnic minorities, low literacy adults) be reached?
- Where does the general public get health/nutrition advice from?
 World Health Organization. Situation analysis and priority setting, 2018.
Appendix 3. Instructions for developing a food database
Instructions for developing a packaged food database through a shop survey
Guidance on conducting a shop survey: Instructions for steps 1-7
Determine the food categories and stores where information will be collected from
The objective here is to collect data on the main foods that contribute to salt in the diet from a range of stores (small shops and supermarkets). The main contributors to salt in the diet can be identified from dietary surveys; however, in most countries key contributors to salt from processed foods are likely to be bread and other baked goods, processed meats and cheeses, canned or salted fish, noodles, crisps and snacks, and sauces and condiments. Sodium content data for all product categories should be collected to ensure the most complete dataset. Products within the same categories should be collected regularly (e.g., annually) to monitor changes in product formulation as well as new product development. The process can be made more efficient by regulating the standardized disclosure of nutrient content of packaged foods. This may include requiring manufacturers to post nutrition information online or creating a surveillance plan to audit products during routine store visits by the Ministry of Health. For most countries, the collection of data should include all nutrients of concern (e.g., sodium, sugars, saturated fats) as well as calories to allow nutrients to be expressed per kcal as well as per 100g.
Set up research team and prepare data collection materials
The size of the research team will depend on the number of processed food products on the market and the need to audit products in stores vs. searching in online databases or receiving standardized information from stores or food processors. For in-store audits, many countries will need a project coordinator and a team of 4-5 people to collect data over a few weeks (generally, a team of two can manually collect/photograph 40 products per hour). Once the team has been established, materials to collect data need to be prepared. Collecting data with a tablet or a smartphone is preferred, but copies of the record sheets can be printed out for manual recording if necessary. Photographs should be taken of each side of the product label, including the Nutrition Facts Label (NFL). The project coordinator should assign each person one or two product categories and all information for all products within the category should be entered.
Gain permission from store owners to collect data
Before data can be collected in stores, seek permission from store owners. Usually, it is sufficient to go and introduce yourself and explain what you are doing when you get to the shop but in some cases, it may be necessary to send a letter first and then follow up with a visit to request permission prior to conducting the survey.
Conduct surveys (recording information from the packaged food labels)
Option 1: Manual data collection
The research team will record information from all food items using a data collection template. Each product should be given a number. Even if the sodium data is missing from a product, the other product details should be recorded. If a product is not labelled or the label is in a different language this should also be recorded so that it will be possible to calculate the percentage of products without labels or that are incorrectly labelled. Photographs of product labels and NFLs is helpful for documentation and data verification. Sometimes, only photographs are taken during the actual in-store visit, and data from the photographs is entered into the template at a later date.
Step 4a – Find the Nutrition Facts Label
Step 4b – Find the information for ALL of the criteria in the table below
Primary Format Brand name Name of brand as per product label Product title Name of product as per product label Manufacturer Manufacturing company as per product label Country of manufacturer Country where product was made as per product label Pack size grams or millilitres Serving size grams or millilitres Sodium per 100g milligrams / 100 grams or 100 millilitres Sodium per serve grams or milligrams per serve if provided Date obtained date (dd/mm/yyyy) Data source Name and location of shop
Step 4c – Copy the information from the nutrition information panel into the data collection template
Option 2: Using a smartphone data collector application
An alternative to collecting the data manually is to use a smartphone-based application, such as the George Institute for Global Health’s FoodSwitch mobile App, the Food Label Information Program (FLIP) App from the University of Toronto, and the NutrINSPector App developed by the National Institute of Public Health of Mexico (INSP). Generally, these applications assist countries in collecting information about the nutritional composition of processed foods in the supermarket. The apps can be used to take photos of the front of the package, the Nutrition Facts Label (if present), the ingredient list, and scan barcodes if they exist on the package. Photos can be uploaded to a cloud storage server. Photos are viewed there or downloaded to enable a research team to enter the nutrition information for each packaged food item.
If data was collected manually, enter the information from the data collection template into a database (organised by food category)
Manually collected data needs to be entered into a standardised database, often Microsoft Excel, Access, or REDCap. Each item also needs to be put into a relevant food category to ensure that information can be analysed in a systematic way. The categorisation of foods may differ between countries to some extent. However, countries may choose to use broad categorisation systems developed by the WHO or regions (e.g., PAHO) that should enable cross-country comparisons.
Do quality checks of the database: screen for plausibility and check 5-10% of products against original source
The data entry process needs to be verified. A random sample of 5-10% of entries should be selected and the information in the database should be compared against the online records, original in-store audit record sheets, photographs of product NFLs, and if necessary, against the original products in stores. It is important to note that the NFL may not accurately reflect the sodium content of the food. Having a separate process to verify the actual sodium content (through independent chemical analysis of the products) to compare to the NFL is optimal.
Conduct data analyses to determine the mean levels of nutrients in each food category (at minimum)
There should be an initial tabulation that summarises the number of products in each food group and each food category. Mean and median levels (and ranges) for sodium should be calculated overall and, if possible, separately for the leading companies contributing to each food category. The primary analyses should be reported per 100g, but additional estimates can be made per serving if this is relevant. The gold standard is to assess the sales weighted average for sodium in a category; however, most countries do not currently have ready access to sales weighted data.
Information about Global Food Monitoring Group
This resource is adapted from the Global Food Monitoring Group. The health problems caused by processed foods are global and the Global Food Monitoring Group has initiated an international effort to track the nature of processed foods around the world. The ‘Food Monitoring Group’ includes representatives from ~30 developed and developing countries who have developed a protocol for tracking the nutritional composition of processed foods. Low cost, readily available data collection and management tools have been developed and provide a sustainable low-cost mechanism for acquiring data on the nutritional composition of foods at scale. The data will in turn allow monitoring the effectiveness of global efforts to ameliorate ill health caused by processed foods and hold governments and corporations to account for the quality of the products that are marketed. For more information about the Global Food Monitoring Group or using the Data Collector App see: http://www.georgeinstitute.org.au/projects/global-....
This document was developed by Resolve to Save Lives: Dr. Laura Cobb, Nicole Ide, Funke Ajenikoko, Kate Elliott, and Dr. Jennifer Cohn and RTSL consultants: Dr. Norm Campbell and Christine Johnson . The document was also reviewed by the following individuals:
Dr. Renu Garg, Medical Officer - WHO Country Office Thailand
Dr. Sushera Bunluesin, National Professional Officer - WHO Country Office Thailand
Payao Phonsuk, Food and Nutrition Policy for Health Promotion Program, International Health Policy Program Foundation, Thailand
Dr. Champika Wickramasinghe, Ministry of Health, Colombo, Sri Lanka
Dr. Renuka Jayatissa, Medical Research Institute, Ministry of Health, Colombo, Sri Lanka
Dr. Nalika Gunawardena, National Professional Officer (Noncommunicable Diseases and Health Systems) - World Health Organization, Sri Lanka
Dr. Karen Charlton, School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, New South Wales, Australia
Dr. Feng J He, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom
Dr. Eduardo Nilson, Center for Epidemiologic Research on Nutrition and Health, University of Sao Paulo, Brazil
Adriana Blanco-Metzler, Researcher - Costa Rican Institute of Research and Teaching in Nutrition and Health, Costa Rica
Dr. Jacqui Webster, The George Institute for Global Health, University of New South Wales, Australia
Leo Nederveen, Advisor Food, Nutrition and Physical Activity in Schools - WHO Regional Office for the Americas, Pan-American Health Organization
Lorena Allemandi, Consultant - WHO Regional Office for the Americas, Pan-American Health Organization
Azeb Tolessa, Senior Program Manager, Nutrition - Resolve to Save Lives, Vital Strategies
Dr. Zeng Ge, Chief Technical Officer, Sodium Reduction and Surveillance - Resolve to Save Lives, Vital Strategies
Dr. Maryam Al-Mansur, Nutrition Policy Advisor - Resolve to Save Lives, Vital Strategies
Dr. Meenu Singh, Technical Advisor-Nutrition - Resolve to Save Lives, Vital Strategies
Dr. Swati Bhardwaj, Technical Advisor: Nutrition - Resolve to Save Lives, Vital Strategies