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Saint Louis University

School of Nursing
Diego Silang Bldg, A. Bonifacio St., Baguio City

A POLICY ON THE REDUCTION OF


SALT INTAKE AMONG OLDER
ADULTS

In partial fulfillment for the requirements for


NCM106

Submitted by:
LARA, Kit
ROSARIO, Ryle
REALUBIN, Dianne
USON, Emmarie
THIAM, Joybee
BSN IV-D3

Submitted to:
Cherylina Dalilis, RN

May 11, 2018


Introduction
According to the World Health Organization (WHO), chronic illnesses or non-
communicable diseases (NCDs) are the leading cause of death and disability
around the world. One of which is hypertension. As a person ages, large arteries
begin to stiffen which now leads to increased blood velocity from the aorta to
the systemic arterial system (Moore et al., 2003; Weisfeldt, 1998). Cardiovascular
symptoms of hypertension parallel the usual aging changes seen in older adults.

Hypertension causes 7 million deaths every year while 1.5 billion people suffer
from its complications according to WHO; hence, hypertension is considered a
detrimental factor for deaths worldwide. As stated by Dr. Dante Morales,
President of the Philippine Society of Hypertension (PSH) during the National
Hypertension Awareness celebration conducted at the Universidad De Manila
on 19 May 2012, “21 percent of Filipino adults are hypertensive.”

It’s well-established that consuming too much salt can lead to high blood
pressure and other risk factors for heart disease and heart failure. According to
national surveys, adults 51 years and older consume 3,100 mg of sodium per day
on average and fewer than 2% of adults in that age range meet current sodium
recommendations. The 2010 Dietary Guidelines for Americans recommend that
adults over 51 should reduce sodium intake to 1,500 mg daily.

According to the Food and Nutrition Research Institute, salt and soy sauce were
among the top 10 widely used miscellaneous food items used by Filipinos.
Excessive intake of salt and soy sauce can result to high blood pressure
especially to salt-sensitive individuals. Persistent high blood pressure can result to
cardiovascular diseases.

That being said, living a healthy lifestyle plays a significant role in treating
hypertension. One of which is to minimize or reduce salt intake. Decreasing
dietary salt intake will reduce coronary heart disease deaths in the four
countries. A comprehensive strategy of health education and food industry
actions to label and reduce salt content would save both money and lives.

The reduction in population levels of salt intake has been associated with the
implementation of national salt reduction strategy in the United Kingdom. This
national salt reduction strategy introduced in 2003 voluntary agreements with
food industry to reduce salt content in foods and public awareness campaigns
to change personal behavior like reducing salt added during cooking.

Strategies to reduce population levels of salt intake may represent a promising


and highly cost effective way of reducing the growing burden of non-
communicable disease particularly in resource constrained settings. The UK salt
reduction strategy might be expected to reduce known inequalities in
cardiovascular disease because consumption of fresh fruit and vegetables is
lower and consumption of processed foods this may be higher in poorer
communities who are likely to benefit most from comprehensive reductions in
salt content in food by industry.

As of now, a house bill had made its way to the House of Representatives last
2016. It seeks “to impose mandatory warning labels on food products or
processed food products containing sodium and to subject all processed foods
for review on their sodium levels.” On another note, it was also stated in the bill
that “Despite indicating that the leading cause of health-related diseases are
cardiovascular diseases, the DOH has not campaigned or lobbied for food
producers to inform the public about the deadly levels of sodium in their
products.” Hence, the need of a policy to reduce sodium intake in the country
becomes a greater necessity.

Since the people in the Philippines has been reported many cases of high blood
pressure and CVD among older adults, a no salt policy may be implemented to
help reduce these diseases. Following strategies that may help implement this
policy in the Philippines are strategy which involves making reductions in salt in
cheaper food products which are consumed by poorer households, a public
awareness campaign of the risk of high salt intake in older adults especially
when they have high blood pressure and who are at risk of having CVD, and
possible regulation and ongoing monitoring of salt intake levels among older
adults by barangay health care centers.

Implementation
A diet high in sodium is a major risk factor for non-communicable diseases like
cardiovascular disease. Sodium reduction is considered a public health priority
globally.
 Strategy 1: Mandatory 25% reduction in sodium levels in three groups of
processed foods: bread, processed meats, and sauces

Product Maximum per serving


category target (mg sodium per
100 g)
Burgers in bun 960 mg
Sandwich 1500 mg
Pizza 350 mg
Potato 350 mg
products
Bread 450 mg
Breakfast 400 mg
cereals
Cheese 800 mg
Table sauces 680 mg
Adopted from: UK Food Standards
Authority’s salt reduction program

 Strategy 2: A package of interventions: a mix of a mass media campaign,


voluntary food reformulation and food labeling changes.

MEDIA:

The public awareness campaign consisted of two aspects. The main


activity involved the development of one 30 s television advertisement
and two 30 s radio advertisements for the most popular television
channels and radio stations that are utilized by the target population. The
advertisements featured a well-known medical doctor and media
personality who emphasized the message that consuming too much salt
and that too much salt leads to hypertension, which can cause heart
attacks and strokes.

The second aspect of the public awareness campaign included various


supporting activities aimed at strengthening the advertisement message
and providing additional information and education materials regarding
salt reduction. The formulation of website that will obtain more
information on lower-salt recipes will also be made.

Voluntary endorsement food labelling

(The adaptation of “Tick Programme” – an endorsement label program


runs by the Heart Foundation).

The Tick is an independent program which encourages food


manufacturers to improve the nutritional quality of their food products.
The Tick Programme aims to ensure consumers are easily able to identify a
healthier choice within a food category. Foods carrying the Tick are a
better choice in their category, for example bread with the Tick is a
healthier choice of bread because it will have less salt (sodium) and more
fiber than others that may not have the Tick

Food labeling can help motivate consumers to choose lower sodium


products. Some types of labeling can even prompt reformulation so that
products are lower in sodium. Sodium information on labels is provided in
a technical format (milligrams per serving and percent daily value of
sodium), located on the back of packaged food, written in fine print, and
surrounded by other nutrition and ingredient information. Encouraging the
use of labels to reduce intake is a common goal of recent sodium
reduction campaigns. Front of pack (FOP) labels that interpret nutrition
information, as used in Finland and the UK, are more effective. In Finland,
high salt warning labels were successful as part of a larger sodium
reduction initiative. Packaged foods with sodium levels over a specified
threshold determined by the type of food were labeled as a high-salt
product. Food labels help consumers choose packaged foods with lower
sodium, but the labeling system can be improved. Labels that are
prominently placed and consistent have the potential to influence
consumer decisions. Additionally, labeling that indicates high levels of
sodium can encourage manufacturers to reduce sodium voluntarily.
Without reductions in the overall sodium levels in packaged food, even
the best labeling system will not be sufficient to reduce sodium intake.

 Strategy 3: A salt tax*: an excise tax applied and increased up to the point
where the recommended level of sodium intake is achieved (2300
mg/day)
Three public health legal tools often used to deal with products
associated with negative public health impacts include 1) taxes (to
decrease consumer use and raise public health revenues), 2) spending
incentives (to directly influence industry or consumer choices through
financial rewards), and 3) bans (to remove a product from the market or
limit specific consumers’ access). In small amounts, salt is not only safe but
essential. Salt makes food taste better and last longer with no added
calories. Taxing or banning salt or other sodium products may seem
unjustified but it only applies to salty snacks. In 2015, the Navajo Nation
imposed a 2% tax on all junk food sold on its reservation, including an
array of high sodium products of “minimal-to-no nutritional value.”

Banning sodium in all processed foods is impossible, but partial bans may
be viable legally. Limiting or banning access to salty products like canned
fruits and instant noodles for older adults is lawful just the same as bans on
selling tobacco, alcohol, or sugar-sweetened beverages. Prohibiting
overuse of sodium as a flavor or preventive in specific products for certain
populations may be legally defensible provided government can
demonstrate legitimate, correlated public health concerns.

 Strategy 5: Coordinated voluntary reductions

Lowering the sodium content of packaged and restaurant foods are


possible without limiting consumer choice and acceptance. In addition to
adapting over time to a lower salt taste; when given lower sodium food
and a salt shaker, people only add back a portion of the sodium
removed.

This model of coordinated voluntary sodium reductions has been


adapted for the United States by the National Salt Reduction Initiative
(NSRI), led by New York City. It aims to reduce sodium intake by 20% and
sodium in packaged and restaurant foods by 25%. The NSRI has also
created national packaged and restaurant food databases to
independently monitor sodium content. This type of voluntary action has a
number of advantages. It’s significantly less controversial than regulation,
both to food companies and the public. In addition, having specific
sodium reduction targets and an independent database for monitoring,
makes it is possible to hold industry accountable for their commitments.
Critically, it targets packaged and restaurant food sodium content, rather
than consumer behavior. Finally, it is a nuanced system which both
reduces intake over time, allowing tastes to adjust, and distinguishes
between different types of food, maintaining consumer choice and
variety.

 Strategy 6: Dietary Counseling

Individual dietary counselling, whether by physicians or other healthcare


providers, is another important strategy for reducing sodium intake. A
caveat is that advice alone will not allow patients to meet sodium and
other lifestyle recommendations. Physicians play an important role in the
reinforcement and maintenance of behavior change. The physician-
patient encounter offers a valuable opportunity for physicians to promote
lifestyle changes, of which sodium reduction should be a major goal. A
brief supportive message on the benefits of sodium reduction, even
without extensive counseling, should be beneficial. Physician effectiveness
in this role can be enhanced through their increased knowledge, skills,
and a positive attitude towards sodium reduction and other lifestyle
modification.

Features of an effective counseling session with patients include:


assessment of their readiness for change; discussion of the importance of
reduced sodium intake for health; discussion of the overall concept of
diet quality, e.g. DASH diet, with tips for successful adoption; assessment
of patient barriers to adherence with suggestions for better adherence;
goal setting; and distribution of written material. Although clinic visits often
do not allow time to cover of all elements of an effective counseling
session, a good first step is for the physician to protect time in the session
to discuss diet and barriers to dietary modification.

Approaches to provider-patient conversations about lowering sodium intake

Strategies for  Make reading food labels a habit


sodium  Stick to fresh foods (e.g., meats, fruits and
reduction that vegetables) rather than their packaged
counterparts
can be
 Avoid spices and seasonings that contain added
communicated sodium
quickly to  Check restaurant websites before dining out.
patients And, request that your food be prepared without
any added salt.
 In 6–8 weeks, one can adjust to eating less salt
 Cook rice, pasta, and cereals without salt
 Choose “convenience” foods that are lower in
sodium
 Rinse canned foods to remove some sodium
 When available, buy low-sodium, reduced-
sodium, or no-sodium versions of foods
Features of an  Assess readiness for change
effective  Discuss importance of reduced sodium intake
counseling  Discuss overall concept of DASH diet and give tips
for successful adoption
session
 Assess patient barriers to adherence and give tips
for better
 adherence Set goal(s)
 Distribute written material

Tools needed  Assessment of readiness for change


for an effective  Attitude that sodium reduction is possible
counseling  Assessment for barriers to eating well
 Assessment for literacy and numeracy
session
 Sample food label

Proposal
I. Identifying stakeholders

The coordinating group needs to identify the stakeholders with whom it needs to
collaborate and the methods to achieve this. Potential stakeholders can
include:

• Different government departments, e.g. health, trade, food and agriculture,


education, local and regional authorities.
• All sectors of the food industry, including retail associations and catering
groups.
• Health professionals, professional organizations, universities, research institutes
and food safety agencies.
• The mass media.
• NGOs, consumer groups, religious and faith-based organizations and other
non- profit organizations.

Potential barriers
• The producers and distributors of processed foods and meals may have little
awareness of links between salt, health and NCDs, and may be unwilling to
reduce the salt content of their products.
• Stakeholders may not be aware of the dangers of excessive salt intake and
some may view the use of salt in a positive light.
• Many countries do not have identifiable trade and consumer organizations.
• The informal sector is less well defined. Smaller food companies, street vendors
and small caterers may not have representatives and thus are difficult to reach
and get involved.

Countermeasures
• The trust of the food industry can be gained by using an open approach. The
importance of reformulation, the benefits need to be communicated clearly.
Incentives may also be considered.
• Develop a clearly presented document highlighting the evidence base for
action on salt reduction
• Mapping techniques can be used to identify where business interests lie and
how different groups associate, for example some may use the same supplier.
• Respected academics or scientists may use their influence to spread the
message to other academics and NGOs in order to lobby for reformulated food
products.
• International organizations and NGOs can share support and resources with
smaller local organizations

II. Engaging the food industry and other stakeholders

Having good working relationships with a critical mass of key industry


representatives and other stakeholders is essential. The coordinating group
needs to have a working knowledge of the food industry. The importance of
local vendors and small caterers should also be taken into full consideration.

Potential barriers
• The food industry may disengage if profits or market share are affected. It can
also try to influence policy through “umbrella organizations” and paid
consultants.
• Resources may not be sufficient to engage all sectors of the food industry.
• The presence of fast food chains is increasing in many developing countries
where they may be considered the elite food choice.
• The majority of processed foods may be imported from neighboring countries
and there may be limited opportunities to influence changes in these products.
Countermeasures
• The coordinating group can start by identifying progressive companies,
already engaged in reformulation and work with them as champions in their
sectors.
• The coordinating group may refer to food technology experts for technical
advice on reformulation of food products.
• The food sector can be motivated by publicly acknowledging progress. NGOs
can also name and praise, or alternatively, name and shame.

III. Engaging the media

The mass media is instrumental in raising awareness and increasing public


knowledge and interest. NGOs and consumer groups often use the media for
advocacy and this may be effective in forcing the food industry towards
reformulation.

Potential barriers
• Preconceptions held by some journalists regarding salt consumption need to
be overcome. Salt is frequently considered a beneficial product, especially
where it is fortified with iodine, and the implications of excessive salt intake, such
as high blood pressure, are not always recognized.
• Sponsoring of the media by the food industry and other commercial influences
can confuse the public.

Countermeasures
• Good engagement with the media from the initial stages, and taking a
proactive approach - e.g. preparation of myth busters and questions and
answers to help address opposition and avoiding highly technical jargon can
ensure a more positive and balanced campaign.
• The coordinating group can identify spokespeople prepared to respond to
requests made by the media.
References
 Mason H, Shoaibi A, Ghandour R, O'Flaherty M, Capewell S, Khatib R, et al.
(2014) A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce
Coronary Heart Disease in Four Eastern Mediterranean Countries. PLoS
ONE 9(1): e84445. doi:10.1371/journal.pone.0084445
 http://www.fnri.dost.gov.ph/index.php/publications/writers-pool-
corner/57-food-and-nutrition/204-nutritional-guidelines-for-filipinos-a-
prescription-to-good-nutrition
 https://www.cardiosmart.org/News-and-Events/2015/01/Study-Questions-
Strict-Sodium-Guidelines-for-Older-Adults
 https://www.foodnavigator.com/Article/2015/01/20/Study-suggesting-salt-
intake-is-less-of-a-risk-for-the-elderly-is-flawed-say-experts
 https://sodiumbreakup.heart.org/pass-by-the-salt-sodium-and-older-
adults
 Millett, C.,Laverty, A.A., Stylianou, N., Bibbins-Domingo, K., Pape, U.J.
(2012). Impacts of a National Strategy to Reduce Population Salt Intake in
England: Serial Cross Sectional Study. PLoS ONE: 7(1).
 Wyness L, Butriss J, Stanner S. (2011) Reducing the population’s sodium
intake: the UK Food Standards Agency’s salt reduction programme. doi:
10.1017/S1368980011000966