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Sodium Reduction Framework /

Interventions for Sodium Added in the Home

There are few effective programs to reduce dietary sodium in populations where the major source is sodium added at home. Most interventions to date have relied primarily on education; however, educational programs are often resource intensive and, on their own, unlikely to meaningfully reduce population sodium intake, especially after the conclusion of the program. Using a multicomponent approach may be necessary to meaningfully address sodium added in the home. The interventions listed in this section focus on scalable solutions that potentially have a larger reach.

  1. Governance
  2. Surveillance
  3. Packaged foods
  4. Food prepared outside the home
  5. Sodium added in the home
  6. Appendices & Acknowledgments
  1. 17 Behavior Change Interventions
  2. 18 Increase Uptake Of Low-Sodium Salt^
  3. 19 Innovative/Other Policies to Decrease Use of Sodium at Home
    1. 17

      Behavior Change Interventions

      While also applicable to foods prepared outside the home or packaged foods, behavior change interventions are particularly important for salt added in the home; this is where people have the most control over their salt intake.

      Successful interventions typically take a comprehensive approach. For example, in Vietnam (Do 2016), the Communication for Behavior Impact (COMBI) framework (Michie 2011) was implemented, which included mass media communication, interventions in primary schools, community communication programs, and targeted communications for high-risk groups, including people with hypertension. Post-intervention, follow up surveys found significant reductions in mean salt excretion (–1.99 g/day based on 24-hour urine samples) as well as significant improvements in knowledge and behavioral outcomes.

      1. 17a

        Media campaigns *^

        Media campaigns can motivate individuals to consume less salt by showcasing the dangers of a high-salt diet, demonstrating how to reduce salt intake (e.g., gradual reductions in salt or high salt condiments; using spices, herbs, and other flavors; checking food labels), and debunking myths related to salt consumption (e.g., rock salt or pink salt contains less sodium, people living in tropical areas need more salt, children need extra salt for growth/development, etc.). Key aspects of a successful campaign include: 1) a clearly identified target audience; 2) key messages that motivate the target audience to reduce dietary sodium based on the major dietary sources; 3) a dissemination plan that fits the communications context, takes political context into account, and capitalizes on earned media; and 4) an evaluation to assess the impact of the campaign. Providing general nutrition information or recommendations to eat healthy foods have not been found to change behavior. When applying an existing campaign from another country, adapting the campaign to the local context is crucial.

        In addition to encouraging behavior change, campaigns can be used to put pressure on government or industry stakeholders as part of the policy development process or to educate consumers about new policies to ensure successful implementation. For example, a mass media campaign was conducted in Chile to inform consumers about the meaning of the new front-of-package warning label policy and encourage them to choose products with fewer/no labels

      2. 17b

        Social marketing

        Social marketing applies commercial marketing principles to influence social behaviors. A strong social marketing framework will 1) identify one segment of the public whose behavior it hopes to influence, 2) ascertain what drives people to consume high salt products, 3) isolate a single, immediate benefit that will make it worthwhile to give up high-sodium products, 4) focus on one behavior to change at a time, facilitating the desired behavior and evaluating the outcome, and 5) deploy surprising messages to catalyze behavior change (Khalig 2019).

        One use of social marketing campaigns is to promote and increase uptake of low sodium products, such as low sodium salt or condiments. Ideally, the campaign would promote the product (low sodium salt or other low sodium food), while considering both the price (cost and access) and place (retail settings). For example, a research study in Peru facilitated the uptake of low sodium salt using social marketing principles, which led to a reduction in blood pressure and an increase in potassium intake (Bernabe-Ortiz, 2020).

      3. 17c

        Settings-based education

        School-based education programmes have the potential to reduce salt consumption among children. Strong programs have created child-friendly icons and characters with positive, aspirational messages connected to healthy foods, and have encouraged children to act as change agents, bringing lessons home to their families. A randomized control trial of a school-based program in Northern China found a significant impact on sodium intake of the child and their family (He 2015).

        Training can be provided to health care workers on the negative health impacts of high salt consumption and strategies for reducing salt consumption, and they can be encouraged to provide salt reduction counseling to their patients, particularly those with cardiovascular disease. For example, a salt reduction intervention in Fiji combined initiatives to engage food businesses to reduce salt in food with targeted consumer behavior change programs (through a health worker training program and public awareness campaign). The intervention resulted in a reduction in sodium intake from 11.7g/day to 10.3g/day (Pillay 2017).

    2. 18

      Increase Uptake Of Low-Sodium Salt^

      Low-sodium salt typically replaces 10% to 50% of the sodium in regular salt with potassium (or in some cases, with magnesium and/or small amounts of other minerals). Interventions or policies to increase the uptake of low sodium salt should address 1) availability to ensure customers have access to low sodium salt by tackling production and regulatory challenges (e.g., access to potassium sources, infrastructure, and efficient supply chains), 2) awareness and promotion (e.g., through education and social marketing campaigns) to ensure the public, shopkeepers, and health workers are aware of the product, 3) affordability to equalize the price of low sodium salt and regular salt (sodium chloride) through use of subsidies, voucher programs, or by taxing regular salt (see Section 13 for more on fiscal policies), and 4) advocacy to ensure low sodium salt is on the governments agenda and garner support from salt industry. Low sodium salt is one of the best strategies for reducing sodium in food made at home and can also be used in food manufacturing (or as part of implementing sodium targets ( Section 11) and in restaurants or food services (Section 16).

      It is important to note that while the added potassium in low-sodium salt can help combat potassium deficiency common in most populations and reduce high blood pressure, replacing more than 25-30% of sodium with potassium is often linked to a bitter or metallic taste. Further, there is some concern that potassium based low-sodium salt has potential for adverse effects due to hyperkalemia, specifically the increased risk of arrhythmias and sudden cardiac death, among individuals with medical conditions or on medications that impair their potassium excretion. While a few case reports of adverse events have been cited, there have been no reported excess risk of adverse events, including severe hyperkalemia, in studies evaluating the effect of low-sodium salts.

      At the population level, overall health is improved with the use of low-sodium salt and risk is low. Given the limited potential risk, low-sodium salts can carry a warning to inform consumers of possible contraindications to low-sodium salt use that may increase risk for hyperkalemia ( JHU, RTSL 2021); however, these warning statements should not discourage consumers who have no contraindications.

    3. 19

      Innovative/Other Policies to Decrease Use of Sodium at Home

      Innovative or incompletely tested interventions are listed where evidence is still emerging or research on impact has been mixed.

      Salt restriction spoons
      Providing salt restriction spoons (usually holds 2g salt) along with instructions for adding salt to food may be helpful for sodium added at home or in small businesses (Chen 2013, Hou 2020).

      Increased access to fresh fruits and vegetables
      Natural foods have very little sodium. Many successful initiatives have improved access to fresh foods to reduce reliance on processed foods high in sodium often used in home cooking. Removing barriers such as price and low availability can help to increase access to fresh foods (E.g., FAO PAA). See Section 13 for more on subsidizing healthy food like fruits and vegetables.

      Interventions on popular foods preserved in salt
      In many regions, meat, fish and vegetables preserved in salt or stored in brine are popular and may even be required for food preservation where refrigeration is not easily accessible.These foods can be store bought or pickled/preserved in the home depending on the country or context. Rinsing, washing or soaking the food in water before cooking or serving can reduce the salt content. More research is needed to determine the most effective methods of reducing salt content while preserving other nutrients and preventing pathogen growth. In Korea, a special refrigerator was developed to allow storage of lower sodium Kimchi.

      Sodium warning labels
      Salt containers can be required to carry a warning label on the front of the package (Campbell 2019). Argentina has developed a regulation requiring that packages carry the warning: Too much sodium in the diet causes high blood pressure and increases risk of stomach cancer, stroke, heart disease and kidney disease. Limit your use.