Policy Options for Reducing Dietary Sodium Intake
DOI:
https://doi.org/10.11575/sppp.v5i0.42387Abstract
Faced with soaring health-care costs, Canadian governments should consider creative ways to enable the population to stay healthy — and making it possible for Canadians to reduce their sodium intake is an extremely cost-effective way to do so. Excess sodium consumption is a risk factor for high blood pressure, stroke and heart disease. On average, Canadians consume 3,400 mg of sodium a day (1,100 mg over recommended levels), at least three-quarters of which comes from processed foods. Any attempt at sodium reduction must therefore involve the food industry. This paper surveys sodium reduction efforts in jurisdictions around the globe, as well as past Canadian attempts, to provide provincial and federal policymakers with a comprehensive suite of lessons learned and a host of far-sighted policy recommendations ranging from food procurement to legislation and private sector engagement. Provincial governments, individually or together, must launch multi-pronged efforts involving food service companies, manufacturers, post-secondary institutes and the media to ensure that low-sodium alternatives are readily available, and that consumers are aware of them. They must also support federal action on changing dietary guidelines and introducing restrictions on food advertising to children. The benefits to be had are very real. In light of evidence showing that population-level intervention is superior to clinical intervention in terms of cost-effectiveness, returning up to $11.10 for every dollar spent and generating tens of billions in direct health-care savings, there is a very strong case for investing in population-level sodium reduction interventions that will work. The time for governments to act is now.References
Aleksandrova K, Pischon T, Weikert C. “Letter: Urinary sodium excretion and cardiovascular disease mortality,” JAMA 2011; 306:1083.
Andersen L, Rasmussen LB, Larsen EH, Jakobsen J. “Intake of household salt in a Danish population,” Eur J Clin Nutr 2009; 63:598-604.
Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, Goldman L. “Projected effect of dietary salt reductions on future cardiovascular disease,” New Engl J Med 2010; 362:590-599.
CBC radio. “Salt: interview with Dr. Norm Campbell, Professor of Medicine at the University of Calgary,” The Homestretch (Alberta programming), July 11, 2011. Available online at: http://www.cbc.ca/video/#/Radio/Local_Shows/Alberta/The_Homestretch/1366093611/ID=2052384638
CIHR Institute of Population and Public Health. Available online at: http://cihr-irsc.gc.ca/e/13777.html
Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. “Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness,” Lancet 2010 11/20; 376(9754):1775-1784.
Cobiac LJ, Vos T, Veerman JL. “Cost-effectiveness of interventions to reduce dietary salt intake,” Heart 2010; 96:1920-1925.
Dall TM, Fulgoni VL, Zhang Y, Reimers KJ, Packard PT, Astwood JD. “Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet,” Am J Health Promotion 2009; 23:412-422.
Dolega-Cieszkowski JH, Bobyn JP, Whiting SJ. “Dietary intakes of Canadians in the 1990s using population-weighted data derived from the provincial nutrition surveys,” Appl Physiol Nutr Metab 2006; 31:753-758.
Drewnowski A. “Obesity, diets, and social inequalities,” Nutr Rev 2009; 67(Suppl 1):S36-39.
Dubois L, Girard M. “Social position and nutrition: a gradient relationship in Canada and the USA,” Eur J Clin Nutr 2001; 55:366-373.
Dutton DJ, Campbell NRC, Elliott C, McLaren L. “A ban on marketing of foods/beverages to children: the who, what, why, and how of a population health intervention,” Can J Public Health in press.
Éditeur officiel du Québec. Consumer Protection Act. 1978:248-249.
Elliott C. “Assessing ‘fun foods’: nutritional content and analysis of supermarket foods targeted at children,” Obes Rev 2008; 9:368-377.
Elliott P, Brown I. “Sodium intakes around the world.” Background document prepared for the Forum and Technical meeting on Reducing Salt Intake in Populations (Paris 5th-7th October 2006). Geneva: World Health Organization, 2007.
Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. “Comparative risk assessment collaborating group,” Lancet 2002; 360(9343):1347-60.
Fischer PWF, Vigneault M, Huang R, Arvaniti K, Roach P. “Sodium food sources in the Canadian Diet,” Appl Physiol Nutr Metab 2009; 34:884-892.
Forte JG, Pereira Miguel JM, Pereira Miguel MJ, de Padua F, Rose G. “Salt and blood pressure: a community trial,” J Hum Hypertens 1989; 3:179-184.
Garriguet D. “Sodium consumption at all ages,” Health Rep 2007; 18:47-52.
Garriguet D. “Canadians’ eating habits,” Health Rep 2007; 18(2), May.
Gase LN, Kuo T, Dunet DO, Simon PA. “Facilitators of and barriers to implementing a local policy to reduce sodium consumption in the County of Los Angeles government, California, 2009,” Prev Chron Dis 2011; 8(2). [Gase et al. 2011a]
Gase LN, Kuo T, Dunet D, Schmidt SM, Simon PA, Fielding JE. “Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the County of Los Angeles,” Am J Public Health 2011; doi:10.2105/AJPH.2011.300138 [Gase et al. 2011b].
Gaziano TA, Bitton A, Anand S, Weinstein MC, International Society of Hypertension. “The global cost of nonoptimal blood pressure,” J Hypertens 2009; 27:1472-1477.
Gifford-Jones W. “Can’t see the salt for the trees: consumers’ taste buds go against a company’s best intentions,” Toronto Star, July 23, 2011.
Girgis S, Neal B, Prescott J, Prendergast J, Dumbrell S, Turner C, Woodward M. “A one-quarter reduction in the salt content of bread can be made without detection,” Eur J Clin Nutr 2003; 57:616-620.
Harris J, Pomeranz J, Lobstein T, Brownell KD. “A Crisis in the Marketplace: How Food Marketing Contributes to Childhood Obesity and What Can Be Done,” Annu Rev Publ Health 2009; 30:211-25.
Hastings G, McDermott L, Angus K, Stead M, Thomson S. The Extent, Nature and Effects of Food Promotion to Children: A Review of the Evidence. World Health Organization 2007. Available online: http://www.who.int/dietphysicalactivity/publications/Hastings_paper_marketing.pdf
He FJ, MacGregor GA. “Importance of salt in determining blood pressure in children: meta-analysis of controlled trials,” Hypertens 2006; 48:861-869.
He FJ, MacGregor GA. “A comprehensive review on salt and health and current experience of worldwide salt reduction programmes,” J Hum Hypertens 2009; 23:363-384.
Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington (DC): National Academies Press; 2005.
Jeffrey B. Technical brief of Bill Jeffrey, LLB, National Coordinator, Centre for Science in the Public Interest, before the Hearing on Healthy Living of the House of Commons Standing Committee on Health, February 3, 2011, Ottawa. Available online at: http://cspinet.org/canada/pdf/english.technicalbrief.pdf
Jeffery B. “The Supreme Court of Canada's Appraisal of the 1980 Ban on Advertising to Children in Quebec: Implications for "Misleading" Advertising Elsewhere,” Loyola of Los Angeles Law Review 2006; 39(237).
Joffres MR, Campbell NRC, Manns B, Tu K. “Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health care costs in Canada,” Can J Cardiol 2007; 23:437-443.
Laatikainen T, Pietinen P, Valsta L, Sundvall J, Reinivuo H, Tuomilehto J. “Sodium in the Finnish diet: 20 year trends in urinary sodium excretion among the adult population,” Eur J Clin Nutr 2006; 60:965-70.
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. “Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data,” Lancet 2006; 367(9524):17471757.
MacGregor GA, Sever PS. “Salt – overwhelming evidence but still no action: can a consensus be reached with the food industry?” BMJ 1996; 312:1287-1289.
Mattes RD, Donnelly D. “Relative contributions of dietary sodium sources,” J Am Coll Nutr 1991; 10:383-393.
McLaren L, McIntyre L, Kirkpatrick S. “Rose’s population strategy of prevention need not increase social inequalities in health,” Int J Epidemiol 2010; 39:372-377.
Mohan S, Campbell NRC. “Salt and high blood pressure,” Clin Sci 2009; 117:1-11.
Mohan S, Campbell NRC, Willis K. “Effective population-wide public health interventions to promote sodium reduction,” CMAJ 2009; 181:605-609.
Nitzke S, Freeland-Graves J, American Dietetic Association. “Position of the American Dietetic Association: total diet approach to communicating food and nutrition information,” J Am Diet Assoc 2007; 107:1224-1232.
Penney S. Dropping the Salt: practical steps countries are taking to prevent chronic non-communicable diseases through population-wide dietary salt reduction. Prepared for the Public Health Agency of Canada, 2009.
Penney S. Dropping the Salt 2: A database of global activities and plans to prevent chronic noncommunicable diseases through population-wide dietary salt reduction. Prepared for the Public Health Agency of Canada, 2011.
Pietinen P, Mannisto S, Valsta LM, Sarlio-Lahteenkorva S.” Nutrition policy in Finland,” Public Health Nutr 2010; 13:901-906.
Power EM. “Determinants of healthy eating among low-income Canadians, ” Can J Public Health 2005; 96(Suppl 3):S37-42.
Puska P. “The North Karelia Project: from community intervention to national activity in lowering cholesterol levels and CHD risk,” Eur Heart J 1999; 1(Suppl):S9-13.
Ransome K. “Assessment of dietary intake in accordance with recommendations to reduce the risk of cancer among adult Alberta residents,” M.Sc. thesis, Department of Agricultural, Food, and Nutritional Science, University of Alberta, 2001.
Raulio S, Roos E, Prattala R. “School and workplace meals promote healthy food habits,” Public Health Nutr 2010; 13:987-992.
Ricciuto L, Lin K, Tarasuk V. “A comparison of the fat composition and prices of margarines between 2002 and 2006, when new Canadian labeling regulations came into effect,” Public Health Nutr 2008; 12:1270-1275.
Riciutto LE, Tarasuk V. “An examination of income-related disparities in the nutritional quality of food selections among Canadian households from 1986-2001,” Soc Sci Med 2007; 64:186-198.
Rose G. The strategy of preventive medicine. Oxford: Oxford University Press, 1992. [Reprinted. Rose’s strategy of preventive medicine. Oxford: Oxford University Press, 2008.]
Schmidt S. “Feds refused proposed plan to cut sodium,” Calgary Herald, December 12, 2011.
Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. “Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis,” Ann Intern Med 2010; 152:481-487.
Sodium Working Group (SWG). Sodium reduction strategy for Canada – recommendations of the Sodium Working Group, 2010. Report available online at: http://www.hc-sc.gc.ca/fnan/nutrition/sodium/strateg/index-eng.php
Stolarz-Skrzypek K, Kuznetsova T, Lutgarde T, Tikhonoff V, Seidlerova J, Richart T. et al. “Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion,” JAMA 2011; 305:1777-1785.
Strazzullo P, D’Elia L, Kandala N-B, Cappuccio FP. “Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies,” BMJ 2009; 339:b4567.
Tanase CM, Griffin P, Koski KG. “Sodium and potassium in composite food samples from the Canadian Total Diet Study,” J Food Composition Analysis 2011; 24:237-243.
Tarasuk V, Fitzpatrick S, Ward H. “Nutrition inequities in Canada,” Appl Physiol Nutr Metab 2010; 35:172-179.
Taylor RS, Ashton KE, Moxham T, Hooper L, Ebrahim S. “Reduced dietary salt for the prevention of cardiovascular disease: a meta-analysis of randomized controlled trials (Cochrane review),” Am J Hypertens 2011; 24:843-853.
Truscott A. “Checking up on Health Check,” CMAJ 2008; 178:386-387.
Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D’Agostino RB, Levy D. “Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study,” JAMA 2002; 287:1003-1010.
Vatanparast H, Dolega-Cieszkowski JH, Whiting SJ. “Many adult Canadians are not meeting current calcium recommendations from food and supplement intake,” Appl Physiol Nutr Metab 2009; 34:191196.
Wang G, Labarthe D. “The cost-effectiveness of interventions designed to reduce sodium intake,” J Hypertens 2011; 29:1693-1699.
Webster JL, Dunford EK, Hawkes C, Neal BC. “Salt reduction initiatives around the world,” J Hypertens 2011; 29:1043-1050.
Weeks C. “Campbell’s adding salt back to its soups,” The Globe and Mail, July 14, 2011.
Wilson K. “The complexities of multi-level governance in public health,” Can J Public Health 2004; 95:409-412.
World Health Organization (WHO). Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation. Geneva: WHO; 2003.
World Health Organization (WHO 2007) Reducing salt intake in populations: Report of a WHO forum and technical meeting, Paris 2006. p 3. www.who.int/dietphysicalactivity/Salt_Report_VC_april07.pdf.
World Health Organization (WHO 2008). Salt as a vehicle for fortification. Report of a WHO Expert Consultation, Luxembourg, 21‐22 March 2007. http://whqlibdoc.who.int/publications/2008/9789241596787_eng.pdf.
World Health Organization (WHO 2010a). Creating an enabling environment for population-based salt reduction strategies: report of a joint technical meeting held by WHO and the Food Standards Agency, United Kingdom, July 2010. Geneva: WHO Press, 2010.
World Health Organization (WHO 2010b). Sodium: Surveillance, Monitoring, and Evaluation. Strategies to monitor and evaluate population sodium consumption and sources of dietary sodium, and relevant knowledge, attitudes and behaviours. Proceedings of a technical meeting jointly convened by WHO and the Government of Canada. Calgary, October 2010.
Downloads
Published
Issue
Section
License
The following is the copyright statement of SPPP.
Copyright © <Author name> <year>. This is an open-access paper distributed under the terms of the Creative Commons license CC BY-NC 4.0, which allows non-commercial sharing and redistribution so long as the original author and publisher are credited.
Publication Copyright and Licensing
The following guidelines and information, provided in six sections, are intended for authors (the “Author”) who are invited to write a paper (the “Work”) for The School of Public Policy Publications (the “Publisher”). The rights and responsibilities conveyed in the SPP Author Agreement will only apply once your paper is accepted for publication. At that point in the publication process, you will be asked to download the form and return a signed copy via e-mail to spppublications@ucalgary.ca. Please review the below information to ensure agreement with SPPP policies.
Section 1: Author’s Grant of Rights
In consideration of the Publisher’s agreeing to publish the Work in The School of Public Policy Publications, the Author hereby grants to the Publisher the following:
1.1 The irrevocable, royalty-free right to publish, reproduce, publicly display, publicly perform and distribute the Work in perpetuity throughout the world in all means of expression by any method or media now known or hereafter developed, including electronic format;
1.2 The irrevocable, royalty-free right to use the Author’s name and likeness in association with the Work in published form and in advertising and promotional materials related to the Work; and
1.3 The irrevocable, royalty-free right to license others to do any or all of the above.
Section 2: Prior Publication & Publication by Others
2.1 The Author agrees not to publish the Work, or authorize any third party to publish the Work, either in print or electronically, prior to publication of the Work by the Publisher.
2.2 The Author agrees not to publish the Work in any publication outlet which is substantially similar to The School of Public Policy Publications for a period of six (6) months after publication of the Work in The School of Public Policy Publications. Substantially similar is defined as a non-subscription, open-access publication outlet with a similar mandate/vision and intended audience.
2.3 Should the Author publish or distribute the Work elsewhere at any time or in any alternate format, the Author agrees to contact The School of Public Policy Publications to inform them of the subsequent publication.
2.4 Should the Author publish or distribute the Work elsewhere at any time or in any alternate format, the Author agrees to make reasonable efforts to ensure that any such additional publication cites the publication in The School of Public Policy Publications by author, title, and publisher, through a tagline, author bibliography, or similar means. A sample acknowledgement would be:
“Reprinted with permission from the author. Originally published in the The School of Public Policy Publications, http://www.policyschool.ca/publications/.”
Section 3: Editing and Formatting
The Author authorizes the Publisher to edit the Work and to make such modifications as are technically necessary or desirable to exercise the rights in Section 1 in differing media and formats. The Publisher will make no material modification to the content of the Work without the Author’s consent.
Section 4: Author’s Ownership of Copyright and Reservation of Rights
4.1 Nothing in this agreement constitutes a transfer of the copyright by the Author, and the copyright in the Work is subject to the rights granted by this agreement.
4.2 The Author retains the following rights, including but not limited to, the right:
4.2.1 To reproduce and distribute the Work, and to authorize others to reproduce and distribute the Work, in any format;
4.2.2 To post a version of the Work in an institutional repository or the Author’s personal or departmental web page so long as The School of Public Policy Publications is cited as the source of first publication of the Work (see sample acknowledgement above).
4.2.3 To include the Work, in whole or in part, in another work, subject to Section 2 above and provided that The School of Public Policy Publications is cited as the source of first publication of the Work (see sample acknowledgement above).
4.3 The Editors and Editorial Board of The School of Public Policy Publications requires authors to publish the Work under a Creative Commons Attribution-NonCommercial 4.0 International licence (CC BY-NC 4.0). This license allows others to distribute, remix, tweak, and build upon the Work for noncommercial purposes, and ensures the Author is credited for the original creation. This onward licensing is subject to section 2.4 of this agreement, which further ensures that the original publisher is credited.
Section 5: Author’s Warranties and Undertakings
The Author warrants that:
5.1 The Author is the sole author of the Work, or if a joint author, the Author has identified within the Work the other authors, and holds the copyright, either solely or jointly, and has the power to convey the rights granted in this agreement.
5.2 The Work has not previously been published, in whole or in part, except as follows:
5.3 Any textual, graphic or multimedia material included in the Work that is the property or work of another is either explicitly identified by source and cited in the Work or is otherwise identified as follows:
5.4 To the best of the Author’s knowledge, the Work does not contain matter that is obscene, libelous, or defamatory; it does not violate another’s civil right, right of privacy, right of publicity, or other legal right; and it is otherwise not unlawful.
5.5 To the best of the Author’s knowledge, the Work does not infringe the copyright or other intellectual property or literary rights of another.
5.6 The Author will indemnify and hold Publisher harmless against loss, damages, expenses, awards, and judgments arising from breach of any such warranties.
Section 6: The Reuse of Third-Party Works
The Publisher requires that the Author determine, prior to publication, whether it is necessary to obtain permissions from any third party who holds rights with respect to any photographs, illustrations, drawings, text, or any other material (“third-party work”) to be published with or in connection with your Work. Copyright permission will not be necessary if the use is determined to be fair dealing, if the work is in the public domain, or if the rights-holder has granted a Creative Commons or other licence. If either the Author or Publisher determines for any reason that permission is required to include any thirdparty work, the Author will obtain written permission from the rightsholder.
