Sodium Reduction Framework

Develop a comprehensive strategic plan

A strategic plan describes the approach the government and other stakeholders will take to lower dietary sodium. It should include: (1) vision and objectives, (2) main interventions and/or policies and their timelines, (3) communications plan, (4) monitoring and evaluation plan, and (5) key stakeholders (for more on stakeholders see Section 1.3).

Other aspects that may be included are an assessment of the political landscape and how different stakeholders will support the objectives. Ideally, the strategy is based on ‘SHAKE’, the World Health Organization (WHO) technical package to support population reduction in dietary sodium and/or regional WHO office strategies. The Pan American Health Organization and the Regional Office for Europe have regional packages/toolkits for salt reduction relevant to strategic planning.

While other countries’ strategies can be used as a model, countries should take into account the unique diets of their population, major sources of dietary sodium, and opportunities and challenges for reducing dietary sodium. The strategic plan should include an overall cost estimate and, ideally, costs per major intervention. The dietary sodium strategy can stand alone or be integrated into a broader noncommunicable disease or nutrition strategy. If dietary sodium reduction is part of a broader strategy, there need to be sufficient resources and priority allocated to successfully implement the sodium reduction-specific interventions.

Regardless of the approach, a successful strategy contains specific interventions to reduce sodium among the country’s primary dietary sources of sodium, whether it comes from packaged foods, food eaten outside the home (e.g., restaurants, canteens, street food), and/or food prepared and eaten in the home.

Successful strategies are usually multi-component approaches that combine a variety of policy measures and behavior change interventions along with a strong monitoring and evaluation component. Examples of comprehensive approaches include the United Kingdom’s salt reduction program as well as the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) program (He 2014, Xu 2020).

As part of strategic plan development, governments will need to understand the existing landscape, set goals, outline operational and organizational details, and assess costs and benefits. Some countries have formed sodium reduction working groups and/or advisory group to oversee the strategic plan. Further elaborations on these topics are provided in the following sub-sections 1A – 1D.

Design and conduct an advocacy strategy

Advocacy—activities to support and influence relevant decision-makers to take the necessary actions to promote a salt reduction strategy—will be critical throughout the design and implementation process. These activities may seek to win general support for salt reduction from the government (including commitments to reduce salt intake in the country and prioritization of salt reduction within the government agenda); it may also aim to convince government officials to support and promote a specific policy that will lead to a reduction in salt intake (e.g., adopting salt targets for packaged food, front-of-pack labeling, etc.)

Advocacy is frequently led by civil society groups or other non-profit or academic institutions. Involvement from these groups, and the constituencies they represent, expands the scale and diversity of support for sodium reduction measures; their visible backing for sodium reduction policies can counter opposition from industry and support government stakeholders to take action. Advocacy may also be conducted within the government itself; program leaders may need to convince other officials in order to obtain buy-in within the Ministry of Health; the Ministry of Health may need to obtain buy-in from other agencies such as Ministries of Trade or Finance that are traditionally less focused on health outcomes.

Before designing an advocacy strategy, ensure there is a clear definition of specific goals for sodium reduction (See Section 1.1c), and outline the changes that need to occur for the salt reduction strategy to move forward (See Section 1.1d). Once goals are defined, review findings from the situational analysis (Section 1.1a) to better understand the political and social contexts and identify opportunities as well as threats (e.g., SWOT analysis) for getting sodium reduction onto the current public health agenda, if it is not yet a priority. Also determine what tools and resources are available (e.g., existing data, previous sodium reduction experience and lessons learned in-country or from other countries, financial resources). In most cases, current data on sodium intake, sources, and/or content of foods is important for bringing sodium reduction into the public agenda and convincing stakeholders to take action. Identify key research gaps (refer to the situational analysis) and determine methods and actors/groups to fill these gaps.

Next, build a coalition or network of organizations interested in salt reduction or its related policies. This should start with a stakeholder analysis that examines various actors’ potential roles, level of support (or opposition), and power/influence to determine who to involve to make progress on each goal. Once allies (government bodies, civil society, NGOs, researchers, etc.) are identified and incorporated into the network, the network can meet to agree on common actions (media or political actions), amplify advocacy messages, and ensure a coherent call to action among diverse groups, such as children’s rights, sustainable food systems groups, obesity prevention organizations. Organizational priorities and agendas will vary, but working to find common long-term goals and to highlight partner achievements can encourage collaborative partnerships.

Finally, determine the target audience of the advocacy strategy. This should also derive from the results of the stakeholder analysis, in particular who has the power to make the necessary changes to achieve the identified goals (it may be a different decision-maker or group of decision-makers for each goal). Target audiences often include ministries of health, education, agriculture, and finance, food and drug administrations, and legislators.

Effective advocacy activities take into account what matters to the target audience and tailor arguments to appeal to that audience. Some audiences may find information about the negative health impacts of sodium and the health benefits of policy action compelling; others may find information about cost-effectiveness persuasive. For some decision makers, public and/or media support for the issue may also be critical (especially in the face of industry opposition). Also, consider how sodium reduction may support other policy goals, such as improving children’s health, providing nutritious school food, or supporting local agriculture. In general, it is important to anticipate and address potential concerns from stakeholders and build arguments to address them.

Once you have the building blocks in place, a comprehensive advocacy strategy can be created.This strategy can include many forms of advocacy: strong advocacy efforts include multiple complementary activities.

Advocacy activities commonly conducted by civil society and other groups include:

• Providing background research, fact sheets or policy briefs to decision-makers
• Arranging in-person meetings, phone calls, briefings or workshops with government stakeholders
• Testifying at hearings or presenting at conferences on the health harms of excess sodium and existing successful models in other countries/cities
• Generating relevant local data (e.g., data on sodium content of commonly consumed packaged food products, etc.) and designing advocacy material to inform decision-makers and/or the public about relevant data
• Conducting public awareness campaigns to build public support (using paid mass media, social media, and other channels to reach the public and other stakeholders)
• Contact journalists and/or provide journalist trainings to raise awareness about the importance of salt reduction and advocate for specific action where relevant
• Pursuing earned media coverage (e.g., newspaper or television mentions, placement of op eds in support of sodium reduction strategies)
• Identifying champions that may help get the issue into the public agenda

Advocacy activities commonly conducted by government organizations include:

• Convening workshops and presenting evidence on the need for and benefits of sodium reduction
• Sharing progress reports, publishing press releases, or participating in multi-sectoral mid-term reviews with policymakers to highlight the impact of sodium reduction interventions that are underway (progress reviews also provide an opportunity to address concerns or challenges identified during policy implementation)

Engage stakeholders

Throughout the process of developing and implementing a national sodium reduction strategy, numerous types of stakeholders will be engaged (see Section 1.3c for examples). This section describes key steps to identifying stakeholders through a stakeholder analysis, engaging stakeholders, and building support among important stakeholder individuals and groups.

Mitigate conflicts of interest

The food industry is one of the largest in the world (and a dominant industry in many countries); it has long opposed policies and regulations that could impact its profits. Industry associations at both the global and national level represent the commercial interests of the food industry and will likely oppose policies that reduce sodium in their products. The food industry has created and funded organizations to evaluate science from an ‘industry-friendly’ perspective by creating educational programs and hiring scientists and clinicians to represent industry interests and often funds their meetings and presentations (Campbell 2021). The source of funding may not be disclosed or can be misrepresented (by using a third-party organization, such as the International Life Sciences Institute (ILSI), or funding to an academic or health organization).

Creating a structured approach for industry and people with industry ties to comment on a draft policy, without including them in policy development or final decision-making, is strongly recommended. There are several policies and/or regulations that can reduce the impact of conflicts of interest during the policy process. Best practice is to: 1) Define conflicts of interest broadly and comprehensively; 2) Require written disclosure of financial interests at regular intervals (e.g., annually) by all parties involved; 3) Include groups acting in the public and public health interest (e.g., academics, civil society, etc.) as part of the policy process; and 4) Develop strategies for mutual accountability and monitoring.

Develop surveillance, monitoring and evaluation plans

A surveillance, monitoring and evaluation plan should establish ways to measure progress toward the goals outlined in the strategic plan (Section 1.1), including:

• Baseline and follow-up measurements of average population sodium intake
• Major sources of dietary sodium and the levels of sodium in foods targeted by the program
• Monitoring of interventions, which can include process indicators to monitor whether actions have been implemented in the timeframe outlined in the operational plan
• Interim indicators, such as the knowledge, attitudes, and practices (KAP) of segments of the public, which can contribute to monitoring program progress, barriers, or facilitators (see Section 2.2e).

The plan should outline the frequency of measuring key indicators and should include the required budget, the necessary research and laboratory capacity, and the steps required to build capacity if needed. It is ideal to assess all population indicators in a representative sample with adequate statistical power to examine changes over time and among specific sub populations of interest (e.g., different ethnic populations who may have unique dietary patterns, men vs. women, and key age groups).

Initiatives to reduce dietary sodium can begin while baseline data is being collected, provided the major sources of dietary sodium are known (understanding that the intervention may impact the baseline data).

Surveillance, monitoring, and evaluation plans are often developed and overseen by the sodium reduction advisory or working group; however, in many cases academic institutions or other research groups may be involved. It may be useful to have an independent group conducting surveillance activities. Surveillance of sodium intake and sources of salt can also be built into regularly schedule population surveys, such as WHO STEPS survey or the Demographic and Health Surveys. Additionally, ongoing monitoring and evaluation can be built into existing systems, for example, within health services or food safety systems.

The checklist in Appendix 1 can be used to structure a regular program review

Collect sodium indicator data

The Surveillance, Monitoring, and Evaluation Plan (Section 2.1) will outline indicators that should be established at baseline and repeatedly measured throughout and after interventions take place. This section describes the key indicators to measure, including mean sodium intake; dietary sources of sodium; sodium content in packaged foods; iodine intake and fortification levels; and knowledge, attitudes, and practices related to sodium.

Program transparency and accountability

Once established, indicators for reducing dietary sodium should be made easily and publicly accessible to encourage transparency and accountability for the program. Making data available to the health and scientific community for analysis and dissemination applies pressure on the food sector to meet sodium targets in their products and on program leaders to meet overall program goals. Consumer protection groups can play an important role in ensuring accountability through communications with the public.

Regular program review

Sodium program operational plans (Section 1.1d) need to be reviewed and adjusted to account for lessons learned. Regular program review (e.g., annually) by the working group or other body identified in the strategic plan should assess progress towards targets and also take into account overall trends in dietary intake and sources.

Nutrient profiling models

Nutrient profile models classify foods according to their nutritional quality. Government-led nutrient profiling is critical to the implementation of nutrition policies such as front-of-pack labels, fiscal policies and marketing regulations on unhealthy foods. Industry-developed labeling programs that rely on nutrient thresholds are part of marketing a company’s products and are not appropriate for public health interventions. Nutrient profiles specify thresholds for each nutrient (most include only harmful nutrients such as sodium, sugar and saturated fat). Nutrient thresholds may or may not vary by category. Some nutrient profile models focus on identifying foods that people should avoid, some on identifying better-for-you foods, and others on creating a system to rate foods based on overall healthfulness. The type of nutrient profile will depend on how the model will be used. For instance, in marketing restrictions, a nutrient profile model establishes thresholds above which products cannot be marketed to children, whereas certain front-of-package labels classify foods into multiple categories (e.g. red, yellow or green for traffic light labels) and therefore require a nutrient profile model that provides multiple thresholds.

Countries can often utilize existing nutrient profile models from another country with effective nutrition policies, as long as the model can be adapted to fit the new context based on the food categories commonly consumed. The WHO has developed regional nutrient profile models, mostly for restricting marketing of unhealthy food to children. These may be adapted for other policies as well (see the resources section below for links to the WHO nutrient profile models).

Labeling interventions for packaged foods

Labeling of packaged foods for sodium content (and other nutrients with critical health impact) provides consumers with information so they can avoid less healthy products and select healthier products; labeling also stimulates industry reformulation and new product development.

Government-led sodium targets for packaged food*^

Setting targets for salt levels in packaged foods is a WHO “Best Buy” intervention for addressing non-communicable diseases (NCDs). Sodium targets work best when they are government-led and accompanied by robust monitoring and accountability systems. Salt targets can be voluntary or mandatory. The initial phase of United Kingdom’s government-led voluntary targets resulted in a 15% reduction in salt intake and successfully reduced salt in many categories (He 2014); however, many other voluntary programs have been less successful, given that industry has less incentive to reformulate under voluntary programs. Mandatory targets may have a greater impact on the sodium levels in foods than voluntary approaches (Cobiac 2010).

Targets can be set for maximum levels of sodium content by food category and/or for the average levels of sodium by food category. If sales information is available, which is rare, the sales-weighted average can be used to set targets by food category (Institute of Medicine 2010). Maximum levels are easier to develop and monitor and lend themselves better to a regulatory approach; however, because they affect only the foods highest in sodium, they often have less impact on overall sodium consumed and need to be lowered over time.

Ideally, targets cover a majority of packaged foods in a country (e.g., the UK set targets for 84 food groups in 2020). If this is not possible, and certain categories can be identified as the prime sources of sodium intake, targets can be set for a smaller set of categories to start with (e.g., bread, condiments). The targets and timelines for sodium content of food categories are usually revised at defined intervals and reset to lower levels over time while also adding any new food categories that are significant contributors to sodium intake.

Restrictions on marketing to children^

Unhealthy food and beverages are often marketed to children. Food marketing can impact a child’s food and drink preferences, eating behavior, and food intake. WHO recommends restricting or prohibiting the marketing of unhealthy foods to children. Marketing restrictions should be robust, clear and evidence-based. The ideal marketing regulation 1) is mandatory; 2) protects children under the age of 18; 3) includes all forms of marketing (e.g., social media, in-store, television, radio, internet games, promotions in schools, sponsorship of children’s events, etc.); and 4) uses a nutrient profile model to decide which products cannot be marketed. To be effective, marketing restrictions cannot only affect programs and activities narrowly targeted at children but should also include marketing for a broader audience often seen by those under 18. Ideally, as in Chile, this should align with packaged food warning labels, food procurement standards for schools and other government institutions.

Marketing restrictions may be imposed more broadly to promote healthy eating for everyone. For example, in 2018, London, England restricted advertising for foods and non-alcoholic drinks high in fat, salt and/or sugar on all public transportation, including railways, buses and taxis (Mayor of London 2018).

Fiscal policies

Taxation is a well-established public health approach to reducing consumption of tobacco and alcohol. Taxes on sugar-sweetened beverages have been gaining momentum and have been shown to reduce consumption of sugar when the taxes are substantial; the evidence for other types of food taxes is still being established. A small number of countries, including Mexico, Hungary, Fiji, Tonga, and Saint Vincent and the Grenadines, have instituted junk food taxes or taxes on products that are high in sodium, sugar or saturated fat. These types of taxes may be effective in reducing both the sodium content in food products as well as the amount of high- sodium foods purchased and consumed by the public.

Taxes should be high enough to deter consumption and structured so that substitute products are healthier than taxed products. Taxes to reduce salt intake could either target high-salt foods specifically or junk foods more broadly. Combining taxes with subsidies for healthy foods (e.g., fresh fruits and vegetables) may help offset any burden that taxation may impose on lower-income people who do not change their purchasing patterns (and also increases purchasing of healthy foods).

In addition to taxation, other fiscal policies include:

• Reducing costs of healthy foods by subsidizing fruits and vegetables or other healthy foods, which can also impact purchasing behaviors and potentially reduce dietary sodium
• Tariffs on the import of unhealthy foods

Innovative/other policies for packaged foods

Innovative or incompletely tested interventions are listed where evidence is still emerging or research on impact has been mixed.

Food based dietary guidelines
Brazil and some other countries are moving towards guidelines that promote fresh or minimally processed foods and discourage consumption of highly processed foods. While these are not specifically targeted at changing packaged foods, they aim to disrupt the global trend toward increasing reliance on packaged foods.

Placement, price and marketing of healthy and unhealthy foods in grocery stores
The “4 Ps” of marketing (product, placement, price, and promotion) are used by food retailers to market foods to consumers and can be used to create an enabling environment for healthier choices. Researchers have found that price discounts, product promotions (e.g., food tastings), and visible/accessible placement are the most effective strategies for increasing sales of healthy foods (Hartmann-Boyce 2018, Moore 2014). While this has been studied extensively, there have been no large-scale public health interventions of this kind to date.

Location of food retailers relative to schools
Some jurisdictions have regulated what kinds of foods can be sold in establishments that are near schools. For example, the India School Children Regulation and the South Korea ‘Green Food Zones’ specify what foods are prohibited for sale and marketing within a designated perimeter of school grounds.

Prohibiting sales of unhealthy food to children
In addition to restricting marketing of unhealthy foods to children, multiple jurisdictions in Mexico have recently developed regulations that restrict the sale of unhealthy food to children unless they are accompanied by a parent. The feasibility and impact on reducing dietary sodium has not yet been assessed.

Healthy public food procurement and service policies*^

In many settings, significant amounts of food are purchased with public funds and are served and sold in public institutions (e.g., schools/school meal programs, parks, hospitals, correctional facilities, government office canteens/cafeterias). Establishing and implementing a comprehensive healthy food procurement and service policy for all government agencies increases public access to healthier meals and snacks, with more fresh and less ultra-processed food. A food procurement and service policy sets standards for healthier eating environments, provides internal consistency with a dietary sodium reduction program, and may also prompt the food industry to develop lower sodium products in order to compete for government contracts.

Public food procurement and service policies can be combined with other policies to reduce sodium, such as front-of-package labeling (Section 3.2c) and marketing restrictions (Section 3.4) to create a more effective and comprehensive package of interventions. It can also incorporate other strategies such as the use of low-sodium salt (Section 5.2) and public educational approaches (Section 5.1) to complement implementation of the policy. Further, these policies can be used as a model which can be adopted by private entities to serve or sell healthier, lower-sodium food.

Restaurant and street food interventions

Evidence on restaurant or street food interventions is still emerging; few have been evaluated and where they have, the results have been mixed. Some of the strategies outlined below could apply to all restaurants or street vendors (Section 4.21a), while others are limited to chain restaurants (Section 4.2b). Alone, many of the strategies below may have minimal impact; however, that impact could be greatly increased if implemented together with low-sodium salt substitution (Section 5.2). Additionally, consumer-facing education approaches can encourage ordering of low-sodium dishes.

Behavior change interventions

While also applicable to foods prepared outside the home or packaged foods, behavior change interventions are particularly important for salt added in the home; this is where people have the most control over their salt intake.

Successful interventions typically take a comprehensive approach. For example, in Vietnam (Do 2016), the Communication for Behavior Impact (COMBI) framework (Michie 2011) was implemented, which included mass media communication, interventions in primary schools, community communication programs, and targeted communications for high-risk groups, including people with hypertension. Post-intervention, follow up surveys found significant reductions in mean salt excretion (–1.99 g/day based on 24-hour urine samples) as well as significant improvements in knowledge and behavioral outcomes.

Increase uptake of low-sodium salt^

Low-sodium salt typically replaces 10% to 50% of the sodium in regular salt with potassium (or in some cases, with magnesium and/or small amounts of other minerals). Interventions or policies to increase the uptake of low sodium salt should address 1) availability to ensure customers have access to low sodium salt by tackling production and regulatory challenges (e.g., access to potassium sources, infrastructure, and efficient supply chains), 2) awareness and promotion (e.g., through education and social marketing campaigns) to ensure the public, shopkeepers, and health workers are aware of the product, 3) affordability to equalize the price of low sodium salt and regular salt (sodium chloride) through use of subsidies, voucher programs, or by taxing regular salt (see Section 3.5 for more on fiscal policies), and 4) advocacy to ensure low sodium salt is on the governments agenda and garner support from salt industry. Low sodium salt is one of the best strategies for reducing sodium in food made at home and can also be used in food manufacturing (or as part of implementing sodium targets ( Section 3.3) and in restaurants or food services (Section 4.2).

It is important to note that while the added potassium in low-sodium salt can help combat potassium deficiency common in most populations and reduce high blood pressure, replacing more than 25-30% of sodium with potassium is often linked to a bitter or metallic taste. Further, there is some concern that potassium based low-sodium salt has potential for adverse effects due to hyperkalemia, specifically the increased risk of arrhythmias and sudden cardiac death, among individuals with medical conditions or on medications that impair their potassium excretion. While a few case reports of adverse events have been cited, there have been no reported excess risk of adverse events, including severe hyperkalemia, in studies evaluating the effect of low-sodium salts.

At the population level, overall health is improved with the use of low-sodium salt and risk is low. Given the limited potential risk, low-sodium salts can carry a warning to inform consumers of possible contraindications to low-sodium salt use that may increase risk for hyperkalemia ( JHU, RTSL 2021); however, these warning statements should not discourage consumers who have no contraindications.

Innovative/other policies to decrease use of sodium at home

Innovative or incompletely tested interventions are listed where evidence is still emerging or research on impact has been mixed.

Salt restriction spoons
Providing salt restriction spoons (usually holds 2g salt) along with instructions for adding salt to food may be helpful for sodium added at home or in small businesses (Chen 2013, Hou 2020).

Increased access to fresh fruits and vegetables
Natural foods have very little sodium. Many successful initiatives have improved access to fresh foods to reduce reliance on processed foods high in sodium often used in home cooking. Removing barriers such as price and low availability can help to increase access to fresh foods (E.g., FAO PAA). See Section 3.5 for more on subsidizing healthy food like fruits and vegetables.

Interventions on popular foods preserved in salt
In many regions, meat, fish and vegetables preserved in salt or stored in brine are popular and may even be required for food preservation where refrigeration is not easily accessible.These foods can be store bought or pickled/preserved in the home depending on the country or context. Rinsing, washing or soaking the food in water before cooking or serving can reduce the salt content. More research is needed to determine the most effective methods of reducing salt content while preserving other nutrients and preventing pathogen growth. In Korea, a special refrigerator was developed to allow storage of lower sodium Kimchi.

Sodium warning labels
Salt containers can be required to carry a warning label on the front of the package (Campbell 2019). Argentina has developed a regulation requiring that packages carry the warning: Too much sodium in the diet causes high blood pressure and increases risk of stomach cancer, stroke, heart disease and kidney disease. Limit your use.

Appendix 1. Sodium reduction program checklist

The following Excel file provides an interactive checklist that summarizes each step within the Sodium Reduction Framework. It can be used to track and monitor the status and progress of current sodium reduction programs, identify gaps in national strategies, and provide direction for prioritization in future programs and strategies.

Download Appendix 1 (.xlsx)

Appendix 2. Example content of a situational analysis for preparing a sodium reduction strategy

The WHO describes a situational analysis as “an assessment of the current health situation…fundamental to designing and updating national policies, strategies and plans.”^[1]

An in-depth description of how to conduct a situational analysis for a national health policy is described in the WHO Situation Analysis in the Health Sector and includes a list of the stakeholders who should be involved, key characteristics of the analysis, links to tools for conducting an analysis, and a sample outline of a report. A participatory approach, which includes making information available to citizens and representatives from sectors that intersect with health, can enhance transparency and accountability. The analysis should assess not only the context for reducing population sodium intake, but the underlying causes, such as the social determinants of health, that have contributed to high sodium intake. It can also include a description of stakeholder roles and responsibilities, to understand which organizations hold formal and informal power.

The situational analysis may include answering the following types of questions to assess the strengths, weaknesses, opportunities, and threats to creating a national sodium reduction strategy:

Political support and opposition:

• What level of support and opposition to reducing dietary sodium exists at multiple levels (political, food industry, general public, health and scientific community) and how is this support expected to change over time?
• What are the expected economic and health advantages of a sodium reduction program?
• Are current policies to minimize financial conflicts of interest adequate?
• Is there likely to be organized opposition from individual companies, food industry groups or other organizations?
• Are there strong platforms to monitor food and salt industry influence (e.g., consumer protection groups)?

Monitoring and Evaluation:

• What data has already been collected on sodium intake, sources, or content in foods?
• How do levels of sodium intake and sources of sodium vary by geography, age, ethnicity, gender, or for other subgroups?
• What surveys, research and laboratory services are available to estimate overall sodium intake, the major dietary sources of sodium and the sodium levels of key foods and what steps need to be taken to fill any gaps?
• What is the perception of the general public on the main sources of sodium in the diet, the health impact of consuming too much sodium, and the importance of reducing sodium intake?

Strategy:

• What financial and other resources are available or likely to be obtained?
• What are the program needs that can be filled by key stakeholders and collaborators (e.g., education and advocacy, research, monitoring and evaluation, technical skills without conflicts of interest in reducing sodium content of foods)? This should include a stakeholder mapping exercise.
• What healthy food policies are already in place/planned; do they or can they integrate sodium reduction directly (e.g., sodium targets for foods) or indirectly (e.g., healthy public food procurement)?
• What regional and international legal frameworks could help/hinder the promotion and implementation of sodium reduction policies?
• Are there any current communication campaigns, by public health agencies or food companies, about nutrition and health or sodium intake specifically?
• How can critical groups, such as the household food purchaser/preparer, and vulnerable groups (e.g., ethnic minorities, low literacy adults) be reached?
• Where does the general public get health/nutrition advice from?

[1] World Health Organization. Situation analysis and priority setting, 2018.

Appendix 3. Instructions for developing a food database

INSTRUCTIONS FOR DEVELOPING A PACKAGED FOOD DATABASE THROUGH A SHOP SURVEY

Guidance on conducting a shop survey: Instructions for steps 1-7

Information about Global Food Monitoring Group

This resource is adapted from the Global Food Monitoring Group. The health problems caused by processed foods are global and the Global Food Monitoring Group has initiated an international effort to track the nature of processed foods around the world. The ‘Food Monitoring Group’ includes representatives from ~30 developed and developing countries who have developed a protocol for tracking the nutritional composition of processed foods. Low cost, readily available data collection and management tools have been developed and provide a sustainable low-cost mechanism for acquiring data on the nutritional composition of foods at scale. The data will in turn allow monitoring the effectiveness of global efforts to ameliorate ill health caused by processed foods and hold governments and corporations to account for the quality of the products that are marketed. For more information about the Global Food Monitoring Group or using the Data Collector App see: http://www.georgeinstitute.org.au/projects/global-….

Acknowledgements

This document was developed by Resolve to Save Lives: Dr. Laura Cobb, Nicole Ide, Funke Ajenikoko, Kate Elliott, and Dr. Jennifer Cohn and RTSL consultants: Dr. Norm Campbell and Christine Johnson . The document was also reviewed by the following individuals:

Dr. Renu Garg, Medical Officer – WHO Country Office Thailand

Dr. Sushera Bunluesin, National Professional Officer – WHO Country Office Thailand

Payao Phonsuk, Food and Nutrition Policy for Health Promotion Program, International Health Policy Program Foundation, Thailand

Dr. Champika Wickramasinghe, Ministry of Health, Colombo, Sri Lanka

Dr. Renuka Jayatissa, Medical Research Institute, Ministry of Health, Colombo, Sri Lanka

Dr. Nalika Gunawardena, National Professional Officer (Noncommunicable Diseases and Health Systems) – World Health Organization, Sri Lanka

Dr. Karen Charlton, School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, New South Wales, Australia

Dr. Feng J He, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, United Kingdom

Dr. Eduardo Nilson, Center for Epidemiologic Research on Nutrition and Health, University of Sao Paulo, Brazil

Adriana Blanco-Metzler, Researcher – Costa Rican Institute of Research and Teaching in Nutrition and Health, Costa Rica

Dr. Jacqui Webster, The George Institute for Global Health, University of New South Wales, Australia

Leo Nederveen, Advisor Food, Nutrition and Physical Activity in Schools – WHO Regional Office for the Americas, Pan-American Health Organization

Lorena Allemandi, Consultant – WHO Regional Office for the Americas, Pan-American Health Organization

Azeb Tolessa, Senior Program Manager, Nutrition – Resolve to Save Lives, Vital Strategies

Dr. Zeng Ge, Chief Technical Officer, Sodium Reduction and Surveillance – Resolve to Save Lives, Vital Strategies

Dr. Maryam Al-Mansur, Nutrition Policy Advisor – Resolve to Save Lives, Vital Strategies

Dr. Meenu Singh, Technical Advisor-Nutrition – Resolve to Save Lives, Vital Strategies

Dr. Swati Bhardwaj, Technical Advisor: Nutrition – Resolve to Save Lives, Vital Strategies