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Title: Interested in developing a national program to reduce dietary salt?

Authors: N Campbell, B Neal, G MacGregor

Reference: Journal of Human Hypertension 2011; published online 31 March 2011 (open access through WASH)
http://bit.ly/ij82hf

Summarized by: Benn Grover, Editor, ProCor

Summary
Developing a national program that reduces dietary salt intake is considered one of the most effective ways to improve the health of a nation overall. Most hypertension and CVD experts lack the training for governmental advocacy or developing NGO national programs aimed at reducing salt levels. Three experts who have led various large-scale salt reduction programs in their respective countries (the UK, Australia, and Canada) outline 13 components needed to develop a successful nation-wide salt reduction program.

Leadership
Individual and organizational leadership is one of the most critical components to developing a national salt reduction program. Strong leadership will bring with it respect and access to funding and resources, as well as build a strong enough foundation that will support a campaign that could potentially last several decades.

Environmental scan of facilitators and barriers to the program
One of the first steps is to identify what factors will either support or be a barrier to the program. Current national policies and organizations and individuals that will support the program are key components to identify. Barriers may include food companies, trade organizations, and food industry-supported health organizations.

Estimating the impact of the program on the health of the country
In order to receive support and influence policy, the health impact of population-wide salt reduction needs to be estimated. Most estimates will need information on salt intake and hypertension and CVD rates. In the absence of appropriate data, using a similar country's data may prove helpful.

Building support
Building a coalition or network is critical to creating strong advocacy efforts around the program. The coalition or network should include a core group of dedicated individuals from the health care, scientific, and public media/communication fields.

Establish a solid scientific basis for the salt reduction program
A core set of recent scientific research will allow vested individuals and organizations to address important topics and questions and educate various audiences about the need for a salt reduction program.

Develop a policy statement
A policy statement should include the scientific rationale as well as action steps needed by various stakeholders (the government, various industries, the health care sector, etc). This statement should be endorsed by relevant organizations/institutions and distributed widely. Hypertension Canada, PAHO, the Institute of Medicine, and Health Canada have produced useful templates.

Interacting with industry and government
Direct interaction with industry and the government should occur after a unified coalition of scientific and health care organizations is established. This ensures the program will receive the support needed to defend against organizations and individuals opposed to the program. The authors recommend a voluntary-based approach to salt reduction as opposed to legislation that mandates compliance. The voluntary approach should be coupled with a threat of legislation and constant media publicity which will in turn incentivize food companies into action.

Use media to engage the public and politicians
Politicians are motivated by public support, and one or more organizations should actively engage the media to educate the public and garner support. Develop a communication campaign that builds on topics the media is interested in, such as: salt consumption compared to recommended levels, harmful health effects, comparison of salt content in food, and whether a country has different levels of salt content in foods across different countries.

Industry supported public opposition to the salt reduction program
Citing national and international research and position statements is the most effective way to eliminate individuals who are opposed to a salt reduction program. In general, the media is well-aware of conflicts of interests and will rarely cover an opinion that is opposed to the consensus of national health care organizations and is detrimental to national public health.

Maintaining action in the long term
Once the national government takes a central role (after successful ground-laying work by all stakeholders), the advocacy program should turn to long-term maintenance, and monitor if the government is moving in the right direction in a timely fashion. The key components that should come from a national salt reduction program include: a targeted reduction in salt additives with timelines; an evaluation program that studies salt intake, sources of salt, and salt content of foods; an awareness and education program; and a research program that supports salt reduction.

Form international partnerships
International partnerships provide an opportunity to share best practices. Organizations such as the World Action on Salt and Health, the World Hypertension League, the WHO, and PAHO provide resources, networks, and policy statements that can aid in developing a national salt reduction program. Using the coalition to develop supporting and broader health policy. A salt reduction program should not be created in a bubble. Rather it should partner with other relevant health policy initiatives, such as: mass consumption of processed foods, sugar reduction, and advertisement bans. However, the program should not be too ambitious in its goals, and the messaging should not be a simple, all-encompassing "eat healthy" message, but should be directly related to salt reduction.

National context
A salt reduction program should be tailored to fit the individual profile of a particular country. For the most part, in developed countries, salt intake comes from processed foods, whereas in developing countries, salt is added to the food at home or while cooking. Also, the key stakeholders and barriers to developing a program will be different in each country, and any salt reduction program needs to address that.

Health care and scientific professionals and organizations are not as active as they should be in advocacy efforts to reduce population-wide salt levels. However, they are positioned to lead advocacy efforts that could ultimately lay the groundwork for a nation-wide salt reduction program.