Sodium Reduction Framework /

Interventions for Food Prepared Outside the Home

Sodium intake from food prepared outside the home—such as from canteens, restaurants and street vendors—is increasing in many countries, as people have less time to prepare food at home and more income to spend on prepared food. Reducing sodium in these environments can be challenging, as the industry is often made up of large numbers of lightly regulated (or unregulated) small businesses; however, a number of innovative strategies have been proposed. Additionally, governments can introduce standards for foods the government purchases, serves or sells, impacting large numbers of people and setting an example for the private sector. In some cases, cities or states may have jurisdiction in these environments.

  1. Governance
  2. Surveillance
  3. Packaged foods
  4. Food prepared outside the home
  5. Sodium added in the home
  6. Appendices & Acknowledgments
  1. 15 Healthy Public Food Procurement Standards*^
  2. 16 Restaurant and Street Food Interventions
    1. 15

      Healthy Public Food Procurement Standards*^

      In many settings, significant amounts of food are purchased with public funds and are served and sold in public institutions (e.g., schools/school meal programs, parks, hospitals, correctional facilities, government office canteens/cafeterias). Establishing and implementing a comprehensive healthy food procurement policy for all government agencies increases public access to healthier meals and snacks, with more fresh and less ultra-processed food. A food procurement policy sets standards for healthier eating environments, provides internal consistency with a dietary sodium reduction program, and may also prompt the food industry to develop lower sodium products in order to compete for government contracts.

      Public food procurement policies can be combined with other policies to reduce sodium, such as front-of-package labeling (Section 10C) and marketing restrictions (Section 12) to create a more effective and comprehensive package of interventions. It can also incorporate other strategies such as the use of low-sodium salt (Section 18) and public educational approaches (Section 17) to complement implementation of the policy. Further, these policies can be used as a model which can be adopted by private entities to serve or sell healthier, lower-sodium food.

    2. 16

      Restaurant and Street Food Interventions

      Evidence on restaurant or street food interventions is still emerging; few have been evaluated and where they have, the results have been mixed. Some of the strategies outlined below could apply to all restaurants or street vendors (Section 16A), while others are limited to chain restaurants (Section 16B). Alone, many of the strategies below may have minimal impact; however, that impact could be greatly increased if implemented together with low-sodium salt substitution (Section 18). Additionally, consumer-facing education approaches can encourage ordering of low-sodium dishes.

      Global: Ding J, et al. Systematic Review on International Salt Reduction Policy in Restaurants. Int J Environ Res Public Health. 2020 Dec 21;17(24):9570.

      1. 16a

        Key interventions for all types of restaurants

        Leverage existing packaged food salt reduction strategies to reduce salt in foods purchased by restaurants
        Ensuring that salt reduction targets for packaged foods (whether voluntary or mandatory) apply to ingredients purchased by restaurants and street vendors will likely reduce sodium levels in restaurant foods. Additionally, regulations for restaurants could leverage labeling schemes such as front-of-pack warning labels and restaurants could be required to avoid purchasing products with warning labels. While this strategy is untried, it is based on successes setting sodium thresholds for purchased foods in public food procurement policies and also trans fat thresholds for restaurant purchases of packaged foods as part of trans fat restriction policies (Angell 2009).

        Angell et al. Cholesterol control beyond the clinic: New York City's trans fat restriction. Ann Intern Med. 2009 Jul 21;151(2):129-34.

        Require that salt shakers and condiments high in sodium be available by request only
        Several countries have restricted restaurants from placing salt shakers and high-salt condiments on tables, usually in combination with an education campaign. Customers must request the salt shaker and condiments. Similarly, if restaurants use individual salt packages, these can also be provided only upon request and the size of the package can be reduced (e.g., from 1 g to 0.5 g salt per package) to help encourage reduced consumption.

        Uruguay: NPR. The Salt. Assault on Salt: Uruguay Bans Shakers in Restaurants and Schools. 2015.

        Argentina: Argentina Food Law 26.905. Sodium consumption. Maximum Values. Article 5G. 2013.

        Require restaurants to make a certain number of menu items with no or low added salt
        To enhance customer choice within the restaurant setting, a few jurisdictions require that a certain number (or percentage) of menu items are low-salt or no salt added. Highlighting these items, often in combination with a mass media campaign about the health impact of sodium intake, can provide consumers with important information, particularly outside the chain restaurant environment, where nutrition information is limited. This intervention is likely to mostly benefit customers already motivated to reduce salt intake.

        Montevideo, Uruguay: Devex. Cities and NCDs: Montevideo's menu for reducing sodium intake. 2018.

        Require a sodium warning statement on menus
        Cities and countries can put mandatory policies in place requiring a health message about sodium intake and its relationship to health outcomes on menus and/or menu boards. These warning statements are sometimes only required in chain restaurants, where there is also access to nutrition information, and can be used in combination with high-sodium warning icons on specific menu items.

        Global: Musicus AA, et al. Online randomized controlled trials of restaurant sodium warning labels. Am J Prev Med. 2019 Dec;57(6):e181-e193.

        New York City, USA: Anekwe AV, et al. New York City's sodium warning regulation: from conception to enforcement. American journal of public health. 2019 Sep 1;109(9):1191-2.

        Create targeted education campaigns for restaurant staff and/or chefs
        Many restaurant strategies include an educational component for restaurant staff, which can be delivered during mandatory food safety training required to receive a food handler license or specific training opportunities for restaurant chefs. Trainings may include information on the harms of excessive sodium intake, tips on developing new menu items with reduced sodium content, and ways to work with suppliers to source lower-sodium ingredients. Toolkits distributed to restaurants (e.g., Ma 2018) may include recipes, kitchen utensils and a standard measuring spoon.

        While this education and training can complement other interventions and target particularly vulnerable communities, it is resource-intensive and may be hard to scale. Other interventions should be used in tandem to ensure the continuity of the sodium-reduction strategy.

        Philadelphia, USA: Ma et al. Evaluation of a Healthy Chinese Take-Out Sodium-Reduction Initiative in Philadelphia Low-Income Communities and Neighborhoods. Public Health Reports. 2018 Jul;133(4):472-80.

      2. 16b

        Interventions for chain restaurants

        Require public disclosure of nutrition information at every point of sale
        As a first step, all chain restaurants should be required to publicly disclose nutrition information through a nutrition board/cards for all standard menu items, along with toppings, side dishes, beverages, and promotional items. Information should include all key nutrient information that is often available on packaged food nutrition labels: calories/energy, saturated fat, total fat, trans fat, sodium, sugar, and fiber content, along with ingredients and allergen information.

        Public disclosure of nutrition information allows for tracking nutrient content of menu items in chain restaurants, provides consumers information on nutrition and ingredients, and ensures that public health policies can be monitored and enforced. There is a clear need for transparency in chain restaurant nutrition information to enhance industry accountability and government monitoring of nutrition commitments. Public disclosure of nutrition information should include making it available at the point of purchase where consumers are making decisions—in stores and as part of online ordering for pickup or delivery.

        Require high-sodium warning icons
        Public disclosure of nutrition information requires motivated consumers to check sodium content and understand recommended daily intake limits. At least six policies are in place globally (mostly in North America, Europe, and Hong Kong) that use icons on menus to communicate sodium information to customers, reducing the burden on consumers, and some countries, including the United States and India (to be enforced from January 1, 2022), require calorie labeling on chain menu items. To date, the impact of menu labeling on menu reformulation has been mixed (Alexander 2021), with some studies showing a reduction in the sodium content of menu items and others showing no impact.

        Other Resources:
        Alexander E, et al. Sodium menu labelling: priorities for research and policy. Public Health Nutr. 2021 Apr;24(6):1542-1551.

        New York City, USA: Amaka VA. et al. 2019: New York City’s Sodium Warning Regulation: From Conception to Enforcement American Journal of Public Health. 2019 Sep 1;109(9):1191-2.

        Sweden: Swedish Food Agency. The Keyhole.

        Hong Kong: Hong Kong Department of Health. EatSmart Restaurant Star+ Campaign.

        Set sodium content limits for menu items
        Governments can set thresholds for the total amount of sodium contained in a restaurant menu item. While possible in all types of restaurants, these policies are most feasible for chain restaurants, where ingredient composition is standardized and nutrition information is available. The variation in sodium content that currently exists between restaurant chains in different countries indicates that technical feasibility is not the limiting factor, and substantial reductions could be made that would improve population health (Dunford 2012).To be successful, sodium content limits would likely need to be mandatory.

        Global: Ding J, et al. Systematic Review on International Salt Reduction Policy in Restaurants. Int J Environ Res Public Health. 2020 Dec 21;17(24):9570.

        Global: Dunford E. et al. The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction. CMAJ. 2012;184(9):1023-1028.

        England: Public Health England. Salt reduction targets for 2024. 2020. (See the description on page 4 on the requirements for the out of home food sector to meet certain sodium targets)

        Set sodium (and other nutrient) content limits for meals marketed to children
        Sodium limits can also be set specifically for meals targeted to children. Standards should reflect the appropriate sodium intake for children and may be combined with other nutrient requirements, such as calorie and/or fat limits and minimum servings of fruits and vegetables. A U.S. study found that the majority of meals ordered for children were not from kids’ menus, so any comprehensive policy designed to address children’s health should also encompass limits for all restaurant menu items (Hobin 2014).

        In 2011, the U.S. city of San Francisco put in place nutrient thresholds for chain restaurant meals marketed to children, including a limit of 640 mg of sodium per menu item (Otten 2014). While the restaurants did not change their menus directly in response to the policy, one chain restaurant did make side dishes and beverages more healthful, affecting the overall nutritional profile of orders.

        Australia, Canada, New Zealand, UK and the USA: Hobin E, et al. Nutritional quality of food items on fast-food 'kids' menus': comparisons across countries and companies. Public Health Nutr. 2014 Oct;17(10):2263-9.

        San Francisco, USA: Otten JJ, et al. Impact of San Francisco's toy ordinance on restaurants and children's food purchases, 2011-2012. Prev Chronic Dis. 2014;11:E122.

      3. 16c

        Innovative/other policies for restaurants and street food

        While there are many models for potentially reducing the sodium content of restaurant meals and increasing the number of lower-sodium menu choices for consumers, the following three approaches are innovative and promising, but have not yet been widely used or evaluated.

        Marketing and pricing strategies
        Possible marketing and pricing strategies include proportionate pricing (i.e., eliminating price discounts for large size products); pricing promotions for healthier menu items; and making fruit, salads, water, and other low-sodium items the default choice. Interventions that include how food is displayed and where it is situated on a menu or in a buffet can also affect consumer choices.

        Food ordering websites and applications
        Food ordering websites and applications can be used to promote lower sodium foods. For example, they can introduce prompts, warnings or suggestions to customers while they are placing an order to encourage healthier, lower sodium choices; they can suggest restaurants that offer low-sodium options; and they can rate restaurants according to the healthfulness of food options available.

        India: Swiggy Health Hub

        Food safety infrastructure
        For developing innovative approaches for the street vending environment, the use of food safety infrastructure may be particularly important. A street vendor model has been developed to optimize food safety and nutrition in South Africa, taking into account business viability. Surveys from food vendors in South Africa indicated high consumer willingness to purchase healthier items from street vendors and interest from vendors in organizing wholesale purchasing of healthier foods, both of which might support interventions to reduce sodium consumption (Hill 2019).

        Singapore: Singapore Health Promotion Board. Healthier Dining Programme.

        Nordic: Nordström J, Thunström L. The impact of price reductions on individuals' choice of healthy meals away from home. Appetite. 2015 Jun;89:103-11.

        South Africa: Hill J, et al. The development of an evidence-based street food vending model within a socioecological framework: A guide for African countries. PLoS One. 2019 Oct 22;14(10):e0223535.

        Thailand: Thailand Sodium Lesstaurant program

        New York City, USA: Angell SY, et al. Cholesterol control beyond the clinic: New York City's trans fat restriction. Ann Intern Med. 2009 Jul 21;151(2):129-34. (example of restricting artificial trans fat in restaurants, which may also be relevant to sodium)