A systematic and coordinated national strategy is the best way to make meaningful reductions in sodium consumption across the population. This section outlines the key steps required to develop and lead a strategic plan for sodium reduction, engage key stakeholders and decisionmakers, and minimize conflicts of interest.
- Packaged foods
- Food prepared outside the home
- Sodium added in the home
- Appendices & Acknowledgments
Develop a Comprehensive Strategic Plan
- 2 Design and Conduct an Advocacy Strategy
- 4 Mitigate Conflicts of Interest
Develop a Comprehensive Strategic Plan
A strategic plan describes the approach the government and other stakeholders will take to lower dietary sodium. It should include: (1) vision and objectives, (2) main interventions and/or policies and their timelines, (3) communications plan, (4) monitoring and evaluation plan, and (5) key stakeholders (for more on stakeholders see Section 3).
Other aspects that may be included are an assessment of the political landscape and how different stakeholders will support the objectives. Ideally, the strategy is based on ‘SHAKE’, the World Health Organization (WHO) technical package to support population reduction in dietary sodium and/or regional WHO office strategies. The Pan American Health Organization and the Regional Office for Europe have regional packages/toolkits for salt reduction relevant to strategic planning.
While other countries’ strategies can be used as a model, countries should take into account the unique diets of their population, major sources of dietary sodium, and opportunities and challenges for reducing dietary sodium. The strategic plan should include an overall cost estimate and, ideally, costs per major intervention. The dietary sodium strategy can stand alone or be integrated into a broader noncommunicable disease or nutrition strategy. If dietary sodium reduction is part of a broader strategy, there need to be sufficient resources and priority allocated to successfully implement the sodium reduction-specific interventions.
Regardless of the approach, a successful strategy contains specific interventions to reduce sodium among the country’s primary dietary sources of sodium, whether it comes from packaged foods, food eaten outside the home (e.g., restaurants, canteens, street food), and/or food prepared and eaten in the home.
Successful strategies are usually multi-component approaches that combine a variety of policy measures and behavior change interventions along with a strong monitoring and evaluation component. Examples of comprehensive approaches include the United Kingdom’s salt reduction program as well as the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program (He 2014, Xu 2020).
As part of strategic plan development, governments will need to understand the existing landscape, set goals, outline operational and organizational details, and assess costs and benefits. Some countries have formed sodium reduction working groups and/or advisory group to oversee the strategic plan. Further elaborations on these topics are provided in the following sub-sections 1A – 1D.
Conduct a situational analysis (e.g., strengths, weaknesses, opportunities, and threats (SWOT) analysis)
A situational analysis is critical to successfully adapt the SHAKE technical package to the national context. The analysis should identify key areas of strength (e.g., relevant data available, existing political will and existing multi-sector mechanisms) and weakness (e.g., the population does not have an adequate understanding of the risks of dietary sodium nor how to reduce it) as well as threats (e.g., industry opposition, common myths about salt) and opportunities (e.g., planned revisions to dietary strategy, existing food policies). All existing surveillance data (e.g., sodium intake, sources of sodium) and any previous interventions to reduce dietary sodium should be reviewed, summarized and analyzed.
Establish and demonstrate the potential benefits of dietary sodium reduction, including cost-effectiviness
Sodium reduction strategies save lives and are cost-effective. Asaria et al. estimated that in low- and middle-income countries (LMICs) a 15% reduction in dietary sodium intake over ten years would prevent 8.4 million deaths (Asaria 2007) and cost only $0.04 to 0.32 per person. At the global level, numerous analyses have found that millions of lives can be saved by dietary sodium reduction (Kontis 2019); there are many country-specific cost-effectiveness studies, which can be enormously useful for securing political buy-in and resources. For example, cost-effectiveness data showing a potential 78-to-1 return on investment in South Korea was critical to winning support for the country’s salt reduction program (Park 2020). In the absence of a local study, countries can use tools such as the Global Burden of Disease to estimate how many lives are lost to high sodium intake.
Set short, mid- and long-term sodium intake goals
Establish long-term and feasible mid-term goals for sodium intake, consistent with the WHO goal of adults consuming less than 2,000 mg sodium/day and the commitments made by many countries to reduce sodium intake by 30% by 2025, following the 66th World Health Assembly in 2013. Defined public goals and timelines will help guide program activities, assess progress and enhance accountability.
Acquired taste for sodium, use of sodium as a preservative, changing people’s usual practices in food preparation, length of time to adapt tastes for sodium, as well as eating habits and use of salt alternatives should be considered when creating feasible short (e.g., 2 years, 10% reduction), mid- (e.g., 5 years, 20% reduction) and long-term targets and goals (e.g., 10 years, majority of population consumes less than 2000mg sodium/day). It is recommended to have a mid-term (e.g., 3-5 year) goal that is feasible and based on a national situational analysis (Section 1A). Targets and timelines are important for evaluating the progress of the program over time and for assessing the need for revising interventions and policies.
Examples of mid- and long-term program goals
Short or Mid-term goal
Reduce sodium intake by 30% by 2025
Maximum adult intake of 2,000 mg/day
Reduce the average salt consumption of adults to 7 g/day between 2018 - 2025.
Reduce salt intake by 20% between 2012-2020.
Max salt intake:
- 5 g/day (adults)
- 3-4 g/day (children aged 2–10)
- 0.5 g/MJ (children aged under two)
- No added salt (infants)
National Salt Reduction Initiative*
Reduce population sodium intake by 20%, through a reduction in sodium in US packaged and restaurant foods by 25% by from 2009 to 2014
Maximum limit of 2,300 mg/day
*This program is a partnership of organizations and health authorities from across the United States, convened by the New York City Health Department, that set voluntary salt reduction targets
Establish an operational plan with organizational structure and budget
The findings of the situational analysis (Section 1A) can be used to determine the most appropriate interventions and timelines to meet the established goals (Section 1C). Interventions that address the most prominent sodium sources should be included (see Sections 9-19 for potential interventions). Where these are unknown, surveillance activities to determine the main sources of sodium (Section 6B) should be conducted before selecting specific interventions.
It may also be helpful to review examples of existing sodium reduction interventions from countries around the world. A few organizations provide regularly updated databases or websites that track country examples of sodium reduction policies and interventions. These include the World Cancer Research Fund International’s NOURISHING Database, and the World Action on Salt, Sugar, and Health’s (WASSH) website.
Based on the strategic plan (Section 1), the operational plan assigns specific tasks and timelines for reducing dietary sodium to various stakeholders, defines leadership, and establishes accountability. The operational plan should create a structure to optimize implementation and establish a timeline for regular program review. The structure should facilitate smooth long-term interactions of the various stakeholders, linking the people and organizations that need to work together or who have interdependent work to achieve the short, mid- and long-term goals. See Section 3 for more detail on stakeholder engagement.
An operational plan should also include the budget necessary to carry out the specific activities in the plan. Costs could include: baseline and ongoing data collection on sodium intake, sodium sources, and sodium levels in foods; public education campaigns; policy development and implementation; human resources; establishing a working group or network, etc.
Design and Conduct an Advocacy Strategy
Advocacy—activities to support and influence relevant decision-makers to take the necessary actions to promote a salt reduction strategy—will be critical throughout the design and implementation process. These activities may seek to win general support for salt reduction from the government (including commitments to reduce salt intake in the country and prioritization of salt reduction within the government agenda); it may also aim to convince government officials to support and promote a specific policy that will lead to a reduction in salt intake (e.g., adopting salt targets for packaged food, front-of-pack labeling, etc.)
Advocacy is frequently led by civil society groups or other non-profit or academic institutions. Involvement from these groups, and the constituencies they represent, expands the scale and diversity of support for sodium reduction measures; their visible backing for sodium reduction policies can counter opposition from industry and support government stakeholders to take action. Advocacy may also be conducted within the government itself; program leaders may need to convince other officials in order to obtain buy-in within the Ministry of Health; the Ministry of Health may need to obtain buy-in from other agencies such as Ministries of Trade or Finance that are traditionally less focused on health outcomes.
Before designing an advocacy strategy, ensure there is a clear definition of specific goals for sodium reduction (See Section 1C), and outline the changes that need to occur for the salt reduction strategy to move forward (See Section 1D). Once goals are defined, review findings from the situational analysis (Section 1A) to better understand the political and social contexts and identify opportunities as well as threats (e.g., SWOT analysis) for getting sodium reduction onto the current public health agenda, if it is not yet a priority. Also determine what tools and resources are available (e.g., existing data, previous sodium reduction experience and lessons learned in-country or from other countries, financial resources). In most cases, current data on sodium intake, sources, and/or content of foods is important for bringing sodium reduction into the public agenda and convincing stakeholders to take action. Identify key research gaps (refer to the situational analysis) and determine methods and actors/groups to fill these gaps.
Next, build a coalition or network of organizations interested in salt reduction or its related policies. This should start with a stakeholder analysis that examines various actors’ potential roles, level of support (or opposition), and power/influence to determine who to involve to make progress on each goal. Once allies (government bodies, civil society, NGOs, researchers, etc.) are identified and incorporated into the network, the network can meet to agree on common actions (media or political actions), amplify advocacy messages, and ensure a coherent call to action among diverse groups, such as children’s rights, sustainable food systems groups, obesity prevention organizations. Organizational priorities and agendas will vary, but working to find common long-term goals and to highlight partner achievements can encourage collaborative partnerships.
Finally, determine the target audience of the advocacy strategy. This should also derive from the results of the stakeholder analysis, in particular who has the power to make the necessary changes to achieve the identified goals (it may be a different decision-maker or group of decision-makers for each goal). Target audiences often include ministries of health, education, agriculture, and finance, food and drug administrations, and legislators.
Effective advocacy activities take into account what matters to the target audience and tailor arguments to appeal to that audience. Some audiences may find information about the negative health impacts of sodium and the health benefits of policy action compelling; others may find information about cost-effectiveness persuasive. For some decision makers, public and/or media support for the issue may also be critical (especially in the face of industry opposition). Also, consider how sodium reduction may support other policy goals, such as improving children’s health, providing nutritious school food, or supporting local agriculture. In general, it is important to anticipate and address potential concerns from stakeholders and build arguments to address them.
Once you have the building blocks in place, a comprehensive advocacy strategy can be created.This strategy can include many forms of advocacy: strong advocacy efforts include multiple complementary activities.
Advocacy activities commonly conducted by civil society and other groups include:
- Providing background research, fact sheets or policy briefs to decision-makers
- Arranging in-person meetings, phone calls, briefings or workshops with government stakeholders
- Testifying at hearings or presenting at conferences on the health harms of excess sodium and existing successful models in other countries/cities
- Generating relevant local data (e.g., data on sodium content of commonly consumed packaged food products, etc.) and designing advocacy material to inform decision-makers and/or the public about relevant data
- Conducting public awareness campaigns to build public support (using paid mass media, social media, and other channels to reach the public and other stakeholders)
- Contact journalists and/or provide journalist trainings to raise awareness about the importance of salt reduction and advocate for specific action where relevant
- Pursuing earned media coverage (e.g., newspaper or television mentions, placement of op eds in support of sodium reduction strategies)
- Identifying champions that may help get the issue into the public agenda
Advocacy activities commonly conducted by government organizations include:
- Convening workshops and presenting evidence on the need for and benefits of sodium reduction
- Sharing progress reports, publishing press releases, or participating in multi-sectoral mid-term reviews with policymakers to highlight the impact of sodium reduction interventions that are underway (progress reviews also provide an opportunity to address concerns or challenges identified during policy implementation)
Throughout the process of developing and implementing a national sodium reduction strategy, numerous types of stakeholders will be engaged (see Section 3C for examples). This section describes key steps to identifying stakeholders through a stakeholder analysis, engaging stakeholders, and building support among important stakeholder individuals and groups.
Set the Agenda
To set the agenda and garner key stakeholders and decision makers’ support for implementing a sodium reduction strategy, a fact sheet and call to action (e.g., Campbell 2016) developed by supportive organizations and individuals can be helpful. The fact sheet should emphasize the current levels of sodium intake, the high rates of premature death and disability caused by high dietary sodium and should be tailored to the specific country using available data, such as national-level data from the Global Burden of Disease. The WHO Sodium Country Score Card, which tracks countries' progress in implementing legislative and other measures to reduce dietary intake of sodium, can help countries review progress identify gaps, and compare with other countries. Health economic analyses can play a critical role in winning political support given the high returns on investment and cost savings from dietary sodium reduction programs (Section 1B). The fact sheet can also provide examples of successful salt reduction policies and interventions.
Establish decisionmaker support
Visible, public leadership by a senior government official, such as a Minister of Health, features in many successful dietary sodium strategies. The program needs strong governmental agency secretariat support and budget to provide resources (e.g., financial, staffing) to develop and implement key policies, monitor and evaluate the program and support long-term stakeholder engagement.
Identify and engage key stakeholders
A stakeholder analysis should be conducted to identify the key groups and individuals to engage. Key stakeholders come from many sectors, including government, non-governmental organizations, civil society organizations, academia, media, and the food industry. Stakeholders have different roles to play and should have different levels of influence on the process. The operational plan described in Section 1D can outline the key roles and responsibilities of the stakeholders.
Strong government commitment and oversight is needed for success. Ideally, there should be involvement from multiple government departments, including those responsible for nutrition and food regulations, non-communicable disease prevention, surveillance, food procurement, trade, and marketing, advertising, and broadcasting regulations. Nutritionists, dieticians, and other nutrition-specific program experts will also be useful to engage.
Civil society organizations can be important champions of the work. They can help to expand the scale and diversity of support for sodium reduction activities and keep the pressure on government to act. In many countries, civil society may formally support and assist the government with drafting, reviewing or providing comments, and monitoring policies. Key types of organizations to involve include health advocates (e.g., heart or kidney foundations/associations, consumer protection associations), public health and medical associations (e.g., cardiovascular societies, nutrition societies, family physicians, nurses, dietitians), academics (e.g., epidemiologists, nutritional scientists), and education professionals (e.g., culinary schools, health staff in schools). Engaging global organizations may be helpful to gain insight from ongoing sodium reduction programs in other jurisdictions. Well-known role models (e.g., athletes, celebrities, entrepreneurs, chefs) may also play a role in raising awareness and building support for salt reduction programs and policies.
While the food industry is a stakeholder in many sodium reduction policies and should have a structured opportunity for input on specific policies that impact the industry, this process needs to be transparent and governed by a strong conflict of interest policy (See Section 4).
See Section 2 for further details on stakeholder advocacy.
Counter scientific opposition
In some cases, there may be arguments against sodium reduction by members of the scientific community or other stakeholders. It is important to note that scientific controversy has been created by a small group of scientists who suggest that low levels of sodium can increase cardiovascular mortality. These arguments are based on observational studies that rely on lower quality methods of measuring sodium intake. Other problems in the literature include reverse causality, lack of rigor in research, conflicts of interest and commercial bias (Cobb 2020, Campbell 2021). Rigorous reviews of the evidence for sodium reduction, such as those completed by the National Academies of Medicine or the European Food Safety Authority, have consistently concluded that sodium intake should be limited to 2,000 or 2,300 mg/day to protect cardiovascular health. Stakeholders, especially those from academia, can be involved to counter scientific opposition from other stakeholders using documented high quality, rigorous research from unbiased sources, emphasizing the clear impact of high sodium intake on blood pressure levels and the benefits of sodium reduction on cardiovascular health outcomes.
Mitigate Conflicts of Interest
The food industry is one of the largest in the world (and a dominant industry in many countries); it has long opposed policies and regulations that could impact its profits. Industry associations at both the global and national level represent the commercial interests of the food industry and will likely oppose policies that reduce sodium in their products. The food industry has created and funded organizations to evaluate science from an ‘industry-friendly’ perspective by creating educational programs and hiring scientists and clinicians to represent industry interests and often funds their meetings and presentations (Campbell 2021). The source of funding may not be disclosed or can be misrepresented (by using a third-party organization, such as the International Life Sciences Institute (ILSI), or funding to an academic or health organization).
Creating a structured approach for industry and people with industry ties to comment on a draft policy, without including them in policy development or final decision-making, is strongly recommended. There are several policies and/or regulations that can reduce the impact of conflicts of interest during the policy process. Best practice is to: 1) Define conflicts of interest broadly and comprehensively; 2) Require written disclosure of financial interests at regular intervals (e.g., annually) by all parties involved; 3) Include groups acting in the public and public health interest (e.g., academics, civil society, etc.) as part of the policy process; and 4) Develop strategies for mutual accountability and monitoring.
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