Sodium Reduction Framework /

Interventions for Packaged Food

Addressing sodium consumption from packaged foods is an important component of a salt reduction strategy where packaged food consumption is high or growing. Regulatory approaches are typically most effective for reducing sodium in packaged foods (Hyseni 2017). Multiple strategies exist for reducing sodium intake from packaged foods, including setting targets to lower the sodium content in packaged foods, mandating accurate nutrition labels, fiscal policies (taxation of high-sodium or junk foods/HFSS foods (high fat, sugar, salt)) and subsidies to incentivize consumers to make healthier choices), and limits on what foods can be marketed/advertised to children. One strategy to lower the sodium content of packaged foods without altering taste is the partial substitution of salt with low-sodium salt. Low-sodium salt is discussed further in Section 18.

Resources:

Hyseni et al. Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy? PLoS ONE 2017;12(5): e0177535

  1. Governance
  2. Surveillance
  3. Packaged foods
  4. Food prepared outside the home
  5. Sodium added in the home
  6. Appendices & Acknowledgments
  1. 9 Nutrient Profiling Models
  2. 10 Labeling Interventions for Packaged Foods
  3. 11 Government-Led Sodium Targets For Packaged Food*^
  4. 12 Marketing Restrictions To Children^
  5. 13 Fiscal Policies
  6. 14 Innovative/Other Policies for Packaged Foods
    1. 9

      Nutrient Profiling Models

      Nutrient profile models classify foods according to their nutritional quality. Government-led nutrient profiling is critical to the implementation of nutrition policies such as front-of-pack labels, fiscal policies and marketing regulations on unhealthy foods. Industry-developed labeling programs that rely on nutrient thresholds are part of marketing a company’s products and are not appropriate for public health interventions. Nutrient profiles specify thresholds for each nutrient (most include only harmful nutrients such as sodium, sugar and saturated fat). Nutrient thresholds may or may not vary by category. Some nutrient profile models focus on identifying foods that people should avoid, some on identifying better-for-you foods, and others on creating a system to rate foods based on overall healthfulness. The type of nutrient profile will depend on how the model will be used. For instance, in marketing restrictions, a nutrient profile model establishes thresholds above which products cannot be marketed to children, whereas certain front-of-package labels classify foods into multiple categories (e.g. red, yellow or green for traffic light labels) and therefore require a nutrient profile model that provides multiple thresholds.

      Countries can often utilize existing nutrient profile models from another country with effective nutrition policies, as long as the model can be adapted to fit the new context based on the food categories commonly consumed. The WHO has developed regional nutrient profile models, mostly for restricting marketing of unhealthy food to children. These may be adapted for other policies as well (see the resources section below for links to the WHO nutrient profile models).

    2. 10

      Labeling Interventions for Packaged Foods

      Labeling of packaged foods for sodium content (and other nutrients with critical health impact) provides consumers with information so they can avoid less healthy products and select healthier products; labeling also stimulates industry reformulation and new product development.

      1. 10a

        Mandatory nutrient declaration labels*

        At a minimum, national regulations for packaged food labels should require a list of ingredients in descending order of weight and a nutrient declaration including calories, sodium, potassium, sugar, trans fat, and saturated fat (accurate to within 20%). Independent monitoring of the accuracy of labels is important. According to CODEX guidelines, information on nutrient content should be numerical; for example, expressed in g per 100 g or per 100 ml or per package if the package contains only a single portion. Appropriate back of package labeling alone will not lead to lower sodium intake or lower sodium content of packaged foods but is foundational to other packaged food interventions.

      2. 10b

        Regulations restricting health claims on food packages

        Food manufacturers will often put a health or quality claim on food packages or other marketing materials; these claims may be regulated by the government. CODEX guidelines offer the following definitions for claims on sodium content:

        • Low sodium = not more than 0.12 g per 100 g
        • Very Low sodium = 0.04 g per 100 g
        • Sodium Free = 0.005 g per 100g.

        However, even when regulated, many health claims can be difficult for consumers to understand and may create a “health halo effect,” misleading consumers to believe a product is healthy when it is not. For example, a claim on a package that a food contains “low sodium” may lead a consumer to believe it is healthy when in fact it may be high in saturated fat or sugar. At minimum, health claims should not be allowed on packages of food that contain high quantities of sodium, sugar or saturated fat (or that are otherwise unhealthy based on the government’s nutrient profile).

      3. 10c

        Front-of-package labeling regulations

        More recently, some governments have required that manufacturers place interpretive labels on the front of food packages to help consumers choose healthier products or avoid unhealthy products. A variety of front-of-package labeling (FOPL) systems are in use, with some indicating how healthy a food is based on its nutrient profile (e.g., star- or score-based systems) and others showing whether a product contains high amounts of sodium or other nutrients of concern (e.g., warning labels, traffic lights). To date, the only approach to show impact on improved consumer purchasing after policy implementation is a prominent warning label that highlights that a product is high in sodium, saturated fat, and/or sugar (some countries also include trans fat and/or calories). An evaluation of this model in Chile showed a 22% drop in sales for sugary beverages that had warning labels (studies on sodium purchasing specifically are pending).

    3. 11

      Government-Led Sodium Targets For Packaged Food*^

      Setting targets for salt levels in packaged foods is a WHO “Best Buy” intervention for addressing non-communicable diseases (NCDs). Sodium targets work best when they are government-led and accompanied by robust monitoring and accountability systems. Salt targets can be voluntary or mandatory. The initial phase of United Kingdom’s government-led voluntary targets resulted in a 15% reduction in salt intake and successfully reduced salt in many categories (He 2014); however, many other voluntary programs have been less successful, given that industry has less incentive to reformulate under voluntary programs. Mandatory targets may have a greater impact on the sodium levels in foods than voluntary approaches (Cobiac 2010).

      Targets can be set for maximum levels of sodium content by food category and/or for the average levels of sodium by food category. If sales information is available, which is rare, the sales-weighted average can be used to set targets by food category (Institute of Medicine 2010). Maximum levels are easier to develop and monitor and lend themselves better to a regulatory approach; however, because they affect only the foods highest in sodium, they often have less impact on overall sodium consumed and need to be lowered over time.

      Ideally, targets cover a majority of packaged foods in a country (e.g., the UK set targets for 84 food groups in 2020). If this is not possible, and certain categories can be identified as the prime sources of sodium intake, targets can be set for a smaller set of categories to start with (e.g., bread, condiments). The targets and timelines for sodium content of food categories are usually revised at defined intervals and reset to lower levels over time while also adding any new food categories that are significant contributors to sodium intake.

    4. 12

      Marketing Restrictions To Children^

      Unhealthy food and beverages are often marketed to children. Food marketing can impact a child’s food and drink preferences, eating behavior, and food intake. WHO recommends restricting or prohibiting the marketing of unhealthy foods to children. Marketing restrictions should be robust, clear and evidence-based. The ideal marketing regulation 1) is mandatory; 2) protects children under the age of 18; 3) includes all forms of marketing (e.g., social media, in-store, television, radio, internet games, promotions in schools, sponsorship of children’s events, etc.); and 4) uses a nutrient profile model to decide which products cannot be marketed. To be effective, marketing restrictions cannot only affect programs and activities narrowly targeted at children but should also include marketing for a broader audience often seen by those under 18. Ideally, as in Chile, this should align with packaged food warning labels, food procurement standards for schools and other government institutions.

      Marketing restrictions may be imposed more broadly to promote healthy eating for everyone. For example, in 2018, London, England restricted advertising for foods and non-alcoholic drinks high in fat, salt and/or sugar on all public transportation, including railways, buses and taxis (Mayor of London 2018).

    5. 13

      Fiscal Policies

      Taxation is a well-established public health approach to reducing consumption of tobacco and alcohol. Taxes on sugar-sweetened beverages have been gaining momentum and have been shown to reduce consumption of sugar when the taxes are substantial; the evidence for other types of food taxes is still being established. A small number of countries, including Mexico, Hungary, Fiji, Tonga, and Saint Vincent and the Grenadines, have instituted junk food taxes or taxes on products that are high in sodium, sugar or saturated fat. These types of taxes may be effective in reducing both the sodium content in food products as well as the amount of high- sodium foods purchased and consumed by the public.

      Taxes should be high enough to deter consumption and structured so that substitute products are healthier than taxed products. Taxes to reduce salt intake could either target high-salt foods specifically or junk foods more broadly. Combining taxes with subsidies for healthy foods (e.g., fresh fruits and vegetables) may help offset any burden that taxation may impose on lower-income people who do not change their purchasing patterns (and also increases purchasing of healthy foods).

      In addition to taxation, other fiscal policies include:

      • Reducing costs of healthy foods by subsidizing fruits and vegetables or other healthy foods, which can also impact purchasing behaviors and potentially reduce dietary sodium
      • Tariffs on the import of unhealthy foods

    6. 14

      Innovative/Other Policies for Packaged Foods

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

      Food based dietary guidelines
      Brazil and some other countries are moving towards guidelines that promote fresh or minimally processed foods and discourage consumption of highly processed foods. While these are not specifically targeted at changing packaged foods, they aim to disrupt the global trend toward increasing reliance on packaged foods.

      Placement, price and marketing of healthy and unhealthy foods in grocery stores
      The “4 Ps” of marketing (product, placement, price, and promotion) are used by food retailers to market foods to consumers and can be used to create an enabling environment for healthier choices. Researchers have found that price discounts, product promotions (e.g., food tastings), and visible/accessible placement are the most effective strategies for increasing sales of healthy foods (Hartmann-Boyce 2018, Moore 2014). While this has been studied extensively, there have been no large-scale public health interventions of this kind to date.

      Location of food retailers relative to schools
      Some jurisdictions have regulated what kinds of foods can be sold in establishments that are near schools. For example, the India School Children Regulation and the South Korea ‘Green Food Zones’ specify what foods are prohibited for sale and marketing within a designated perimeter of school grounds.

      Prohibiting sales of unhealthy food to children
      In addition to restricting marketing of unhealthy foods to children, multiple jurisdictions in Mexico have recently developed regulations that restrict the sale of unhealthy food to children unless they are accompanied by a parent. The feasibility and impact on reducing dietary sodium has not yet been assessed.