Drop the salt! Engaging the food industry and influencing the policy agenda

Background: The physiological daily requirement for salt is low (1-2g) and most populations around the world are eating much more than this. Excess salt consumption progressively increases blood pressure levels throughout life, and this is one of the biggest contributors to cardiovascular diseases worldwide. The evidence in support of the adverse effect of salt on human health is very strong and widely accepted. Fortunately there is now increasingly firm evidence demonstrating the health benefits that can be achieved through salt reduction as well as broad consensus that, for most countries, implementing a population-wide salt reduction program would be a highly cost effective way of improving population health. For decades, Australia has been at the forefront of clinical academic research defining the role of salt in high blood pressure. However, while there have been repeated calls for action to reduce salt intakes, there has been little by way of a sustained and coordinated effort to translate the scientific evidence into a co-ordinated salt reduction program. The work done for this thesis describes the development, implementation and interim evaluation of the first concerted effort to establish a national salt reduction initiative in Australia between 2007 and 2010. Methods: A review of the available literature and different national approaches to reducing population salt intake was undertaken in parallel with a series of consultations with stakeholders in Australia and internationally to inform a broad understanding of what might be feasible in Australia. Once the initial research and consultation was complete, implementation strategies were developed. Baseline data were established for 2008 through the development of a branded food composition database documenting the salt content of more than 7000 Australian processed foods and repeated surveys of consumer knowledge and practices related to salt. Programs of work to engage the food industry and government were prioritized and underpinned by a targeted media and communications strategy. A series of interim evaluations of the program were conducted, including an independent stakeholder analysis to evaluate views on program impact. Main outcomes: The limited available studies on salt consumption in Australia showed average salt intakes were way in excess of physiological requirements. While government targets for recommended individual salt intakes had been in place for some time, there was no program in place to try to reduce dietary salt in Australia, with only sporadic industry efforts to reduce salt in selected foods. Baseline surveys on consumer knowledge and behaviour confirmed individuals were taking little action to reduce their salt intakes. There was strong stakeholder support for a co-ordinated salt reduction initiative in Australia. Based on these findings The ‘Drop the Salt!’ campaign was developed to reduce population salt intake through strategies targeting industry, government and consumers. Leadership was endowed in the Australian Division of World Action on Salt and Health, a Non-Governmental organisation supported by a network of professional experts. Based on the experience from other countries strategies to engage the food industry to refonnulate foods and to advocate for government leadership were prioritised. The initial baseline assessment of sodium levels in foods from the branded food composition database demonstrated the potential for reductions in salt for most food categories, supporting the need for a sector-wide program. The food groups with the highest mean sodium content were sauces and spreads (1,283mg/ 100g) followed by processed meats (846mg/ 100g). Cereal and cereal products (206mg/ 100g) and fruits and vegetables (21 1mg/ 100g) had the lowest mean sodium content. Good progress has since been made with the food industry strategy with more than 20 large companies making commitments or developing detailed action plans to reduce salt in foods. The media and communications strategy has elevated the importance of salt amongst stakeholders and the Drop the Salt! campaign has been identified as having influenced the priorities of the Federal govemment’s Food and Health Dialogue. This body is leading a national program of food reformulation focussing initially on salt. However, with targets established for only two food categories so far, in comparison to about 80 each in the UK and the US, progress is slow. Baseline assessment showed only a minority of people taking any action to reduce their salt intakes and changes in consumer behaviour have not been demonstrated. There have been no improvements to food labelling, although a comprehensive review is currently underway. Conclusions and discussion: With only limited resources it has been possible to design and implement a coordinated five year national salt reduction initiative in Australia drawing on experience from other countries. A solid baseline from which to monitor progress has been established and interim evaluations have demonstrated significant progress in a short timeframe particularly in relation to engaging the food industry in efforts to reduce salt in foods. Whilst there has also been some progress with government action, the lack of strong government commitment and leadership is still a significant barrier to effective program implementation. This is reflected in the progress of the Food and Health Dialogue which, at the current rate, will take about twenty years to establish salt targets for all food categories. The Drop the Salt! campaign has been credited with forging new collaborations between stakeholders and salt reduction has offered an achievable entry to food reformulation for many companies and facilitated dialogues across health and industry sectors that were not previously engaged. While it is not possible to absolutely attribute cause and effect for all policy outcomes, and an obvious limitation of this research is that it did not provide a historical context for salt reduction activities in Australia, the research does nevertheless illustrate the important role that a small advocacy group can play in influencing the public health agenda. With the food industry lobbying hard to prevent new regulation and government complying, advocacy organisations such as the Australian Division of World Action on Salt and Health will continue to have a central role in holding both to account. The very large health gains projected from a very modest investment in centrally implemented salt reduction strategies mean that this is not an issue that can be allowed once again to fall off the public health agenda