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STRENGTHENING PREVENTION OF NON-COMMUNICABLE DISEASES IN LOW- AND
MIDDLE-INCOME COUNTRIES
Dietary Policy Interventions in NCD : Salt Reduction (SHAKE)
Rome, Italy, 17 March 2016
Dr Temo Waqanivalu Team Leader, Population-based Prevention Prevention of NCD
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Agenda
• Overview
• Burden of NCD risk factors: Salt and HTN
• WHO Technical Packages and Tools
– SHAKE
• Potential collaboration with Italy
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WHO NCD Targets by 2025
Av 10g salt/day
Av 22%
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Strong evidence for the link between salt and health
Source: He et al. J Human Hypertension, 2008
Primarily linked with CVD
– Sodium consumption increases BP
– BP increases CVD risk
– Age, sex and baseline BP specific effects
Also associated with:
left ventricular hypertrophy, kidney disease, renal stones, osteoporosis, gastric cancer
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Prevalence of Raised Blood Pressure
• Global Prevalence 22% (2014) • Causes est 9.4 million global deaths
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Prevalence of Raised Blood Pressure
Burkina Faso 25.1%; Senegal 24.2% Sudan 24.4%
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Salt Intake
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are sparse and are based on food-consumption data rather than on more accurate measures of
sodium excretion.
Fig. 4.1 Mean sodium intake in persons aged 20 years and over, comparable estimates,
2010
Monitoring population intake of salt/sodium The indicator for monitoring this target is age-standardized mean population intake of salt (sodium
chloride) in grams per day in persons aged 18 years and over (13). Few countries have a baseline
level of population salt/sodium intake, or knowledge of the most common sources of sodium in the
diet. Data need to be gathered from a population-based (preferably nationally representative)
survey, either as a stand-alone survey or as part of an existing one. For instance, in many countries a
subsample of the population used for the NCD STEPS survey (14) is used to estimate data on salt
consumption. The recommended standard for estimating salt intake is 24-h urine collection;
however, other methods such as spot urine, single morning fasting urine and food frequency surveys
have been used to obtain provisional estimates. There may be wide differences in sodium intake
within countries, especially in emerging economies and in countries with rapidly increasing
urbanization and peri-urban populations.
Progress achieved National efforts to reduce population salt consumption are under way in many countries (15–17)
(see Boxes 4.1–4.5). Following implementation of national strategies to reduce sodium in
Comment [mendiss10] : ***
•Average 10g salt/day •WHO Recommendation <5g salt/day
Mean Sodium Intake in persons 20 yrs and over 2010
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Salt Reduction saves lives
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Reducing salt intake is a Very Cost Effective (Best Buy) Intervention
Reduce salt intake in food
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SHAKE technical package for salt reduction
• Identifies the key policies/interventions for salt reduction (technical package)
• Guidance on how to develop a national salt reduction strategy and implement the key interventions (toolkit)
• Global applicability
• Field tested in all regions
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Mongolia
2011 MoH launched salt reduction initiative
Baseline data on salt intake (demographics, KAB related to salt, health, dietary recall, 24h urine)
Av salt intake estimated 11.06g/d (mainly from salted tea, sausage, smoked meats, pickled vegetables, bread and chips)
Pilot initiatives
– salt reduction in factory meals : ↓ intake by 2.8g
– and bread : ↓salt content by 1.6%
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Select the food categories and determine baseline salt
content
Targets of salt content for different food categories i.e.
breads, cheeses etc.
Set targets as averages/means, or maxima; ideally both
Targets can be voluntary or mandatory
Propose a schedule of targets and timelines for
discussion
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Kuwait
4 keys steps in partnership with industry:
1. Educate companies on methods for reducing salt and population benefits
2. Emphasise key role of private sector
3. Determine levels of sodium in local products
4. Create collaborative plan
Reduce salt in bread by 20% in first year
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•Identify behavioural objectives
Objectives
•Conduct situational market analysis
Barriers & facilitators •Design a
communication strategy
Five pointed star of action
•Prepare implementation plan & budget
Detailed plan for strategy •Evaluate the
strategy
Impact & lessons learnt
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Viet Nam and Australia
Communication & Education strategy 1. Administrative mobilization and public
advocacy
2. Community mobilization
3. Advertising
4. Face-to-face engagement
5. Point of service promotion
Reduce salt intake from 15.5 to 13.3 g/day
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Caterers and food outlets
Schools
Hospitals
Faith-based organizations
Workplaces (public and
private)
Army/Police/Prisons
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Shandong, China
SMASH Initiative worked though local govt agencies and health teams at households, school and restaurants settings
o developed salt standards
o trained chefs
o produced lower salt menus
o communications to increase knowledge and raise awareness.
Mid-term evaluation estimate reduction salt use
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Country Progress
Voluntary salt targets Mandatory salt targets Regulation on
labelling
Tax on high salt
products
Use of
Potassium
enriched salt
Reformulation of
restaurant menus
Argentina
Australia
Austria (bread) *
Belgium
Brazil
Bulgaria
Canada
Chile
Denmark
Ireland
Italy (bread) *
Lithuania *
Mexico (bread) *
Poland *
Slovenia
Spain
UK
USA
Argentina
Belgium (bread)
Bulgaria (bread, milk
products & lutenica)
Brazil (mozarella
cheese and cheese
spreads) [soups]
Hungary (bread)
Netherlands (bread)
Portugal (bread)
Paraguay (bread)
South Africa
Finland Hungary
Portugal
China Singapore
USA (National
Salt Reduction
Initiative )
* targets for percentage reduction for food categories over time period rather than max/average levels of salt
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Potential collaboration
• With tools developed next phase is to build capacity in country and regions to help scale up action to reduce salt, prevent and control raised blood pressure and CVD
• Country Prioritization exercise is being carried out in terms of CHD/stroke, population size, political readiness with priority given to lower middle income countries
• Great opportunity on joint work in the Africa region
– High intake of salt
– Highest average raised blood pressure
– Population based prevention highly cost-effective to reduce salt, prevent & control CVD & NCD and save lives
– Preventing the next crisis in addition of putting out the last fire in Africa
