Salt Reduction Initiative of the Pan American Forum for Action on Ncds

Salt Reduction Initiative of the Pan American Forum for Action on NCDs

Report for the 4th Meeting of the SaltSmart Consortium 17-18 September 2015 Jolly Beach, Antigua

Table of Contents

Key Messages ...... 1 I. Background ...... 4 II. Welcome ...... 5 III. Progress with Regional Targets ...... 6 LATINFOODS data on soups ...... 6 The George Institute project in Mexico ...... 6 LATINFOODS data for monitoring regional targets ...... 6 Mondelez ...... 8 Nestlé ...... 8 Healthy Caribbean Coalition ...... 8 Paraguay ...... 10 Suriname ...... 10 Chile ...... 10 American Heart Association ...... 10 IV. The Social Marketing Pilots in the Caribbean ...... 11 University of South Florida, WHO Collaborating Centre on Social Marketing for Social Change ...... 11 Team reports ...... 11 Antigua and Barduda ...... 11 St. Vincent and the Grenadines ...... 12 Barbados ...... 12 Jamaica ...... 13 V. Plenary on Sustaining the Social Marketing Projects ...... 14 Summary of Commitments made to Support the Social Marketing Projects ...... 14 VI. Closing Remarks ...... 15 APPENDIX 1: List of Participants at the 4 th Meeting of the SaltSmart Consortium ...... 17 APPENDIX 2: Meeting Agenda ...... 18 APPENDIX 3: Social Marketing Country Teams ...... 24

Key Messages Progress was reported for both strategic objectives to which the Consortium has stated commitments: harmonization of targets for reduced salt/sodium content in processed food products (uptake of regional targets) and social marketing. The latter is focusing on the ∗ discretionary use of salt/sodium and involves pilot projects in four Caribbean countries – Antigua and Barbuda, Barbados, Jamaica, and St. Vincent and the Grenadines.

In Caribbean and Central and South American countries, discretionary use accounts for substantive amounts of salt/sodium in the diet. It is important for initiatives in these countries to set targets and timelines for processed food reformulations in parallel with strategies to reduce discretionary use.

Regional targets – determining baselines for monitoring processed foods Researchers have collected baselines for the salt/sodium content of several processed food products against which progress with the uptake of the regional targets will be monitored: • teams across nine countries in Latin America used food labels and web sites of fast food restaurants to collect data on the salt/sodium declared in a total of 812 processed soups, determining average sodium content per 100g of product and per ready-to-eat portion; • researchers in 10 countries in the LATINFOODS network gathered nutrient label data for over 11,000 products in the 12 food categories to which regional targets apply.

PAHO will extend support to Caribbean countries to contribute data for products in the same 12 categories.

The label data findings (means and medians of salt/sodium content per food category), compared to both the highest and lowest regional target values per food category, will be published.

The next technical advisory group should consider whether label data, as collected above, should become another principle for establishing and/or updating the regional target values for food categories.

∗ Table salt and certain high-sodium prepared foods that are a sub-set of processed and packaged foods subject to discretionary use in cooking and at the table, specific to the national food culture or to a region or sub-population within a country. Even though used in relatively small amounts at any one time, these products can contribute very high levels of salt/sodium to the diet because they are so frequently consumed. Examples are some pickled foods, salted fish, condiments, sauces (soy sauce, fish sauce, tomato sauce, specialty local sauces), marinades, curry pastes , and soup mixes and cubes.

Mondelez has a preliminary framework for technology transfer, another strategic objective of the SaltSmart Consortium.

Social Marketing – focus on discretionary use The four countries in the Caribbean piloting social marketing projects are supported by PAHO, AHA and the Healthy Caribbean Coalition (HCC), and guided by the University of South Florida (USF) World Health Organization Collaborating Center on Social Marketing for Social Change (WHO CC on Social Marketing).Their target audience for messaging is mothers with young children.

Health authorities and civil society organizations are making significant investments in the pilots. Consortium members made a number of commitments to assist and support the initiatives:

• The American Heart Association has material already developed that can be modified. It can also put together a webinar and organize a communication strategy for continuing education related to a specific event or observance e.g. Caribbean Wellness Day.

• Health Canada has materials for salt/sodium reduction developed thematically (for the home, at the supermarket). For consumer research, it has a 6-point literacy test to guide the preparation of materials.

• Consumers International (CI) can assist HCC with a platform to provide consumer information, and can forward information on how CI works with member organizations. The network of Latin American countries active with dietary salt/sodium reduction (Acción Latino-Americana de Sal y Salud (ALASS)) can be extended to assist with disseminating consumer information in the Caribbean.

• Communicating along its normal channels, HCC can work to make information available and can facilitate in-country leaders/local teams. It can also approach local teams to work with the food navigators in supermarkets. HCC is willing to approach trade unions to be a new partner in promoting healthy lifestyle and diet.

• Nestle has a newsletter that circulates in schools in Jamaica. It can include messages specific to salt and could develop the topic of discretionary use that would reach kids and their parents. It can work with the Jamaica social marketing team and potentially share this information across the region.

• September is health month in the Caribbean, with health promotion as the emphasis. PAHO will use this as a platform to address the discretionary use of salt/sodium.

• The formation of Caribbean Salt Smart Coalition (CSSC), supported by the Healthy Caribbean Coalition in partnership with PAHO and the USF WHO CC on Social Marketing.

I. Background

In May 2012, the Pan American Forum for Action on Non-communicable diseases (PAFNCD) recommended the establishment of a multi-sector, multi-stakeholder group to address the overconsumption of dietary salt/sodium in the Region. PAHO responded in August 2012 by convening governments, civil society, academics and major food and beverage companies, an example of the global momentum to deal with NCDs through holistic “whole of society” approaches. The group branded itself as the SaltSmart Consortium and accepted PAHO’s aim to realize by 2020 the goal of less than 5g salt (2000mg sodium)/person/day, a best buy for public health and for the benefit of all people in the Americas. PAHO, as the lead convener for the Consortium, is positioned to promote consistency and alignment in the approaches of the various sectors participating.

The governments represented in the Consortium have dietary salt/sodium reduction initiatives underway: Argentina, Brazil, Barbados, Canada, Costa Rica, Colombia and Chile. The NGOs have special longstanding relationships with PAHO and have regional coverage: the InterAmerican Heart Foundation, Consumers International and the Healthy Caribbean Coalition. The scientific societies are relevant to the topic and have influence across the Region: the World Hypertension League, the Latin American Society of Nephrology and Hypertension, and the American Heart Association. Private sector participants are those with the highest market share of food products identified as the main sources of salt/sodium in the diets in the Region: Bimbo for bread; Unilever for mayonnaise and spreads; Mondelez for snacks and crackers; Nestle for soups and milk products; and ABIA as the largest regional association of food industries, operating in Brazil. A PAHO Technical Advisory Group on Cardiovascular disease prevention through population-based salt/sodium reduction is leading the technical and scientific work of the Consortium.

The following goals attracted participation in the Consortium: • Create a positive environment that enables consumers to choose low/no salt/sodium food products; • Acknowledge the contributions and achievements of the Consortium; • Share best practices and lessons learned, both positive and negative, on an open and safe platform; and • Support country initiatives to reduce the overconsumption of salt/sodium.

The Consortium has had three meetings. At the first, held in August 2012 in WDC, Consortium members discussed terms of reference and agreed to a draft work plan. At a second meeting in June 2013 in WDC, the Consortium accepted a Strategic Plan (2013-2018) and reached consensus to priorize two areas of work in its Plan: social marketing and harmonizing

salt/sodium reduction targets for the Region. The Consortium then began discussing a way forward with social marketing and agreed to participate in developing and piloting a social marketing campaign. Its first exercise was drafting a creative brief that would serve an advertising agency in designing social marketing messages, based on country formative research, aiming to build consumer demand for low/no salt/sodium products.

The third meeting of the Consortium was held in Brasilia on October 2015. It was dedicated to: acknowledging regional advances in dietary salt/sodium reduction; and advancing the harmonization of existing targets by accepting regional values (upper limits) for the salt/sodium content in 12 key food categories.

This Meeting This fourth meeting of the Consortium elaborates on the progress made with regional targets and with social marketing. Consortium members were to achieve the following objectives: • Present their respective advances with uptake and dissemination of regional targets, and the initial steps for monitoring uptake • Gain an understanding of the consumer research performed by the American Heart Association • Gain an understanding of social marketing for public health and in depth knowledge on the pilot project in the Caribbean • Hear the progress reports from the teams in the Caribbean countries • Discuss and agree to the roles and contributions of Consortium members that can advance the social marketing project in the Caribbean

This Report • This report summarizes very briefly the presentations made at the meeting. It focuses primarily on discussions and decisions made. Full presentations are posted on the PAHO web site at 17-18 September 2015. 4th Meeting of Salt Smart Consortium . App endix 1 has the list of participants and Appendix 2 the meeting agenda.

II. Welcome

Branka Legetic introduced Ms. Ena Henry, Assistant Secretary for health institutions in Antigua and Barbuda; Sir Trevor Hassell, President of the Healthy Caribbean Coalition; and Tomo Kanda, PAHO Advisor on NCDs for the Caribbean. They all welcomed the meeting participants. They stressed the importance of reducing the consumption of salt/sodium in the Caribbean, that it is a cost-effective intervention to prevent and control NCDs. Sir Trevor indicated that there would be significant detail in the upcoming presentations and discussions

about the social marketing pilots underway in Antigua and Barbuda, Barbados, Jamaica and St. Vincent and the Grenadines.

Because the small island countries rely heavily on imported food products and share many aspects of food culture, what is shown to be successful in the social marketing pilots has a good chance for scale-up in other Caribbean countries. It is important for the Caribbean that initiatives to reduce the intake of salt/sodium include food product reformulations and address, in parallel, the discretionary use of salt/sodium at the table and in cooking. It is the latter issue on which the social marketing pilots are focusing.

III. Progress with Regional Targets

LATINFOODS data on soups Adriana Blanco gave the results of research conducted by 12 teams across nine countries in Latin America. Using food labels and web sites of fast food restaurants, they collected data on the sodium declared in a total of 812 processed soups (80 different brands, 47.6% belonging to three trademarks). Average sodium content was 328mg per 100g (ranging from 100 to 880mg/100g) or 788mg per ready-to-eat portion (ranging from 30 to 2100mg per portion). Results show that there are products on the market with lower sodium concentration, as well as some products that have concentration by portion that satisfies the full daily sodium intake.

The George Institute project in Mexico Elizabeth Hernandez presented the Mexican project on food composition data base developed together with WHO CC on salt reduction that involved The George Institute (TGI). The project involved training of lay personnel/ students to collect data in supermarkets using the data collector of TGI. Current data base has around 10,000 products. The plan is to use it for consumer’s education piloting the application Food Switch of TGI.

PAHO-LATINFOODS survey for monitoring regional targets Mary L’Abbé presented the preliminary results from a database with nutrient label data collected from packaged products in stores and from company websites in 10 countries in the LATINFOODS network. Supported by PAHO, researchers gathered data on over 11,000 products in the 12 food categories to which regional targets apply. Fourteen variables were collected using the same methodology, addressing 12 key categories, reviewing company web sites, restaurants menus and retailers/supermarkets. Each country collected 1,300 products with representative sample within each category. Currently, the study has been expanded to 4 more countries including Caribbean. The collected data at national level serve as initial baseline for developing national targets or monitoring existing ones against the regional targets. When finalized, the results will be presented as a technical report and will serve the new TAG as baseline in revision of regional targets after January 2017.

Discussion Bloomberg Philanthropies is supporting Mexico to monitor food and beverages. For the TGI project, having students collect the data helped to control costs. Part of their compensation was the iPods they used.

As to the resistance to data collection of some higher-cost food establishments in the Mexico project, the researchers suspected it was due to sensitivity about their pricing being exposed, and possibly a concern that customers would perceive something being wrong with the products being scanned.

In Costa Rica, public authorities signed agreements with food establishments confirming their right, for the public good, to collect label data and to collect samples to validate the label information through laboratory analysis.

Countries own the data that have been submitted to TGI but the costs of continuing with the TGI project, to ultimately create food switch applications with data specific to countries, are prohibitive. In Costa Rica, the IDRC grant facilitated joining the TGI project.

Australia launched Food Switch through the public media as a free application available to anyone. There has been no research yet on its impact on consumer practice. New Zealand has conducted RCT research on the impacts of traffic light labeling, and Canada will soon begin a new RCT with three groups to test the traffic light system versus star labeling.

In small countries, there is no baseline data on the salt/sodium content of foods or on the main sources in diets, there are no reformulation targets and no consistent food labeling. Where to start?

• Costa Rica began by using the method refined by Brazil, the household budget survey (a standard economic tool to assess consumption), to estimate both intake and main sources of salt/sodium. From there, authorities engaged the food industry to begin target setting. The regional targets are available to small countries as they have been accepted by industry in other countries and agreed to by the SaltSmart Consortium.

• Jamaica has a task force with a mandate to set standards for food labeling, reformulation and on advertising and marketing to children.

• Ministries of health can launch initiatives by convening a panel of technical experts (nationals and from abroad if needed) similar to the TAG guiding the regional initiative. The panel can advise on a step-wise approach that involves multiple stakeholders.

• Specific to determining baseline salt/sodium content for food products, to facilitate comparison with regional targets, even small countries can collect label data using phones and cameras, as was the case in the 10 LATINFOODS countries. PAHO has created a process for country-specific data to be imported to a central database.

It is essential that PAHO and a new TAG disseminate the tools and resources that have been developed and tested over the course of Phases 1 and 2 of the regional initiative. There is also a global toolbox being developed by WHO Headquarters. Outstanding is guidance on surveillance in low resources settings.

The new TAG will consider whether the data on the salt/sodium content of products in the 10 LATINFOODS countries calls for a revisit of the regional targets. It may consider these data as a new principle on which to base regional values. On the other hand, it may decide to stay with its principle that regional targets are to be based on existing country targets and shift the regional values down to the lower limits where the LATINFOODS findings show it is warranted. Similar data should be collected in the Caribbean.

Mondelez Maria Rosa Rabanal described company plans: by 2020 to reduce by 10% the sodium and saturated fats in products, and increase by 25% the portion-control options; and by the end of 2016, label caloric intake on front-of-pack.

She presented a framework on technology transfer: by product category indicating what to replace, key new technology and how it works.

Nestlé Shawna Kidd presented Nestlé’s approach to sodium reduction: through product reformulation; transparent consumer communication on packages; and consumer education. Nestlé is member of the Consumer Goods Forum, whose board has a resolution on health and wellness.

Healthy Caribbean Coalition Maisha Hutton indicated that the challenge in many countries in the Caribbean with adopting the regional targets is the lack of baseline data on the salt/sodium content of food products. And even with baselines in place, there can be barriers to conducting the monitoring needed to sustain an initiative.

Initial steps in Caribbean countries needs to include sensitizing consumers to the health risks of high salt/sodium diets and to the benefits of changing behaviors. For civil society, the social

marketing pilots are an important investment in tools for social change that have the potential for scale up. The four countries need to be supported.

Any best practices emerging among the Caribbean countries, whether specific to salt/sodium reduction or in more general terms, aiming to improve what people eat and the food they buy, needs to showcased e.g. the tax on sodas in Dominica and Barbados.

Discussion The majority of food products imported into the Caribbean are from the United States. The level of readiness of local industries to reformulate is uncertain. Can countries in the Caribbean agree to common standards for food labeling?

Transnationals have some food production in countries in Central America. The sodium content of the formulae can differ from that in other sub-regions and sometimes between countries. Global goals for sodium content are not necessarily effective across countries.

By 2025, Nestlé intends to have all of its markets aligned to standard contents and labeling. It is making step-wise reductions in salt/sodium content. It can share data on the “big 8” nutrients by specific product category. 1

Mondelez is gauging its reductions in salt/sodium content relative to the regional targets by food category on the basis of absolute values and sales volumes of products in the category. Product reformulations in countries can occur at different paces, in some cases determined by availability and cost of certain ingredients. Some brand products have standard maximum sodium levels that apply to all markets. For other products, sodium levels differ by Region, in some cases due to compliance with local agreements. The company is striving to harmonize reductions. Labeling is a global policy. The company is putting “big 4” information on packages. One challenge with labeling is countries having different daily allowances for nutrients.

Industry initiatives are key in countries that do not have mandatory labeling. Is information easy- to-understand, applying the best practices to date?

In countries like Suriname, it is small home-food producers that need to be engaged. The food industry members of the Consortium have agreed to technology transfer; a new tool is expected. The larger food companies have the capacity to research and design labels, and should have the capacity to transfer their experiences.

1 “big 4” = energy, protein, carbohydrates, fat; “big 8” = “big 4” plus sugar, saturated fat, fibre and sodium; big 4 or big 8 given per 100 g or 100 ml of the food or per portion or package

In smaller countries, governments have small pools of resources to distribute across numerous issues. A champion organization or institution needs to take the first step to raise awareness. The PAHO Policy Statement is a ready resource, outlining the roles of various sectors, as is material from WASH. In the case of Costa Rica, the IDRC grant served not only to sensitize the ministry of health regarding the overconsumption of salt but also provided support for interventions that now have potential for scale-up.

Paraguay Gabriela Fretes Centurión described that since 2013, Paraguay has regulated the reduction in the sodium content in bread, covering both artisanal and industrially produced products. After one year of implementation, an analysis of breads showed that 70% of bread makers had reached the reduced level. Yet, Paraguay imports between 70 and 80% of the breads on the market hence reductions in products made abroad will affect Paraguay.

Sodium reduction is part of a national nutrition education campaign. Testing of 400 24-hour urine samples has shown salt intake to be 13g per person per day.

Suriname Anne Getrouw indicated that, assisted by Argentina, Suriname has, as a first step, drafted a short-term action plan for dietary salt/sodium reduction. Next it intends to apply the household budget survey method to determine intake and main sources of salt/sodium, and on the basis of that evidence, will launch a consumer awareness campaign.

Chile Luisa Kipreos explained that sodium reduction in Chile is part of an overall strategy on nutrition and obesity control. Specific to sodium, working with associations of bakers and supermarkets with in-store bakeries, there has been successful reduction of sodium in breads.

The warning label legislation will take full effect by 26 June 2019. There are benchmarks for sodium, energy, total sugars and saturated fats for solid and liquid food products, which if exceeded, will require a “high in” warning.

American Heart Association Diana McGhie described the AHA’s consumer research on knowledge, attitudes and behavior, the tools that the association has and websites and materials that can be tailored for the SM project.

IV. The Social Marketing Pilots in the Caribbean

University of South Florida, WHO Collaborating Centre on Social Marketing for Social Change Carol Bryant described the work of the Collaborating Centre and specifically, the social marketing pilots underway in the Caribbean. Momentum has been established and there are some existing initiatives and some reduced sodium products available that can serve as vehicles for social marketing messages.

Team reports Representatives of the teams from the four countries piloting the social marketing initiatives described to Consortium members their country contexts in terms of NCDs and actions being ∗ taken. Each also gave preliminary findings, specific to the discretionary use of salt/sodium , gathered from their interviews with individuals and key stakeholders, and from focus groups. Team members are listed in Appendix 3.

Antigua and Barduda The Antigua and Barbuda team is made up of representatives of the Antigua and Barbuda Diabetes Association, the Ministry of Health, American University of Antigua, the Mount St. John’s Medical Centre and the Ministry of Education.

The country has a high prevalence of NCDs and associated complications that are among the leading causes of mortality and morbidity, taking a heavy toll on limited health resources.

The team applying the Social Ecological Model concluded that the eating environment has become increasingly challenging with easy access to salty foods and several national dishes that are high in salt. The cost of healthy alternatives is also a concern as well as cultural preferences and early exposure to salty snacks. Mothers who have children attending primary school were selected as the priority target population for social marketing for three reasons: their behaviour can be influenced; they can reach younger children who may be more amenable to behavior change; and the return on investments were perceived as high with both long and short term benefits.

∗ The use of table salt and certain high-sodium prepared foods that are a sub-set of processed and packaged foods subject to discretionary use in cooking and at the table, specific to the national food culture or to a region or sub-population within a country. Even though used in relatively small amounts at any one time, these products can contribute very high levels of salt/sodium to the diet because they are so frequently consumed. Examples are some pickled foods, salted fish, condiments, sauces (soy sauce, fish sauce, tomato sauce, specialty local sauces), marinades, curry pastes, and soup mixes and cubes.

The team used results from concept testing with two focus groups, in-depth interviews with 11 mothers, and with stakeholders representing the Ministry of Agriculture, the National School Meals Programme and the Media to develop a marketing plan. Next steps should include engaging other stakeholders and agreeing on a national coordinator to facilitate the implementation of the marketing plan, and to monitor and evaluate it.

St. Vincent and the Grenadines Patsy Wyllie presented the overall findings from interviews and focus groups and elaborated on some of the responses. Researchers reported that mothers they spoke with were uncertain about cooking with less salt, but were enthusiastic about preparing meals at home. Mothers felt that controlling what children consume outside of the home would be much harder than reducing salt intake in the household. Beverly Liverpool described some complementary activities that were on stream towards building capacity for salt reduction: the Caribbean kidney screening and education program; community blood pressure screening and phase 1 of “Blood Pressure Control through Community Action”; and dietary changes made to the national school feeding programme to reduce salt in the diet e.g. the removal of corned beef from the menu. She also mentioned the “Healthy Islands, Healthy Village Projects”, part of implementation of the NCD multisectoral plan of action (2015 – 2019).

Barbados Applying the social ecological model brought to the forefront that Barbadians prefer highly salted tasty food, persuaded by many traditional practices in food preparation and myths behind the use of salt. It was also noted that convenience, time and cost were factors that guided food choices. Branding in Barbados by fast food chains is very prominent and this has filtered into schools, offices and community centres. More so, trade policies tend to favour cheap unhealthy foods. The priority/target population selected for social marketing were women aged 25 -55 years, the main cooks in the home and grocery shoppers. Focus groups proved to be the best way to gather information from this group. Comparisons are possible between women who worked in the private sector, women who worked in the public sector and those who were unemployed. Stakeholder interviews included: the Ministry of Finance – director of economic affairs; Barbados Agricultural Society – CEO for Media – Manager of News and Public Affairs; Starcom Radio and a canteen operator – the caterer and manager of Alexandra School canteen. The mothers were generally aware of the dangers of excessive salt in their family’s diets and many were trying to instil a sense of healthy eating in their young children although they admitted not knowing how much salt is too much. They reported good success among younger children up to 5 years of age, after which their influence and their capacity to intervene both declined. They felt that any in-home campaign should involve the kids in cooking, because it is fun and they can see what goes in. Mothers also reported it “cost too much to eat healthy” and their food budgets typically gave out after, at most, two weeks of the month, after which they had to buy the most economical

foods, and these were not healthy. Their biggest worries were fast-foods that are popular and aspirational, but expensive and unhealthy. Concerns were also raised over the quality of government school meals. From among several ideas for social marketing, working mothers preferred a celebrity or celebrity chef remaking local family favourites using healthy alternatives. Unemployed mothers favoured using social media to share healthy recipes. They rejected a healthy food aisle, because the costs of these foods were perceived as too high, and the foods were not that healthy. The team conducted an assessment of the costs of the low salt/ no salt products available in Barbados’ supermarkets. They found no major clost differences between products that have less salt and their original formulations. Generally the prices differed by between $0.30 or $0.50. Some of the items identified included; ketchup, Worchester sauce, green seasoning, corn beef, pre-packaged, pre-seasoned chicken drumsticks, canned corn, canned chicken breast, tuna, and BBQ sauce.

Jamaica The Jamaican team conducted a qualitative survey to determine the knowledge, attitudes, beliefs and behaviors of mothers with children ages 5-12 years relating to salt intake and reduction. Ten in-depth interviews were done using convenience sampling. The sample was drawn from mothers attending a screening clinic at the Heart Foundation of Jamaica and the Child Welfare Clinic at the University Hospital of West Indies. The mothers knew that salt intake and ill-health are linked and understood the association between salt and hypertension, kidney failure and dialysis. They related this to future risk for their children. There was however a general confusion with messages on sugar and salt intake. Mothers generally understood that food taste development was primarily driven by what the children were taught in early years. They identified that preparation of food at home, providing low-salt snacks and increasing fruits and vegetables in the diet would help to decrease their children’s salt intake. The primary challenge experience by most mothers was the inability to control salt intake outside of the home, with the school environment being the main concern. This said, they also found it difficult to prepare foods for children due to their busy schedules and also thought that low-salt foods were more costly. Mothers indicated that they would try and support efforts to reduce salt in their children’s diet once the options are feasible and cost effective. Most stakeholders cited government policy as the driving force behind salt reduction, to achieve food labelling, public education and multi-sectoral collaboration. Discussion For the most part, the teams used convenience samples for the focus groups and interviews, based on this, findings cannot be generalized to whole populations. This said, in for example Barbados, 90% of the population is Afro-Caribbean so fairly homogeneous. This is likely the case in several other countries in the Caribbean.

Consumer organizations are developing in the Caribbean e.g. in Jamaica, consumers’ rights are taking hold. But overall, civil society is weak. There is an opportunity for Consumers International (CI) in Latin American to extend its reach to the entities emerging in the Caribbean, to have the pilots as an entry point for joining CI.

V. Plenary on Sustaining the Social Marketing Projects Sir Trevor Hassel remarked that marketing is certainly an effective tool to bring about behaviour change at the population level. Social marketing, for a public health goal like changing dietary behaviour, has never been applied in the Caribbean, making the pilots doubly important. To move forward, the initiative needs support. He encouraged, from each sector represented on the Consortium, the spirit of intention in the discussions on how the SM project can be supported and sustained.

Jim Lindenberger added that the pilot countries are crafting their implementation plans. There are a variety of ways in which Consortium members can add support e.g. organizationally, politically, logistically and in some cases, financially, that can dovetail with what the projects are planning.

Summary of Commitments made to Support the Social Marketing Projects

1) What can you or your organization do, to help mothers of young children lower the discretionary use of salt (i.e. make own spices mixes and sauces with less salt, add less salt, select low salt options)?

AHA has collateral material that has already been developed that can be modified.

Health Canada has materials for salt reduction developed thematically (for the home, at the supermarket), and for consumer research, has a 6-point literacy test to guide the preparation of materials.

CI can assist HCC with a platform to provide consumer information, and can forward information on how CI works with member organizations.

HCC can work to make information available and could facilitate in-country leaders/local teams. It can also approach local teams to work with the food navigators in supermarkets.

Nestle has a newsletter that can include messages specific to salt. It could develop the topic of discretionary use of salt that would reach kids and their parents. It can work with the Jamaica team and potentially share this information across the region.

2) How could you and your organization promote messages or sponsor activities to encourage mothers to use less salt at home?

Use existing cultural events and capitalize on global observances e.g. Caribbean Wellness Day, World Heart Day, WASH events, Day of the Child.

AHA can put together a webinar and organize a communication strategy for continuing education related to a specific event.

HCC can communicate along its normal channels. Some international days are recognized by health NGOs, sometimes MoHs.

ALASS can assist with dissemination.

September is health month in the Caribbean with health promotion (Caribbean Wellness Day). PAHO can use this as a platform to promote using less salt/sodium in food preparation.

3) What partners could you mobilize to help?

HCC will approach the trade unions.

4) What could you and your organization do to make low salt options more accessible in schools and supermarkets?

Nestle has a children’s periodical that circulates to schools in Jamaica. It can include an article that discusses a health issue like dietary salt.

VI. Closing Remarks Branka Legetic summarized that the SaltSmart Consortium is participating now in two parallel and concrete projects consistent with its strategic objectives. With the regional targets it is encouraging countries and food industries to adopt same or similar food reformulation targets for common food categories. Now with these initial contributions to the social marketing works-in-progress in the Caribbean, it is addressing the discretionary use of salt/sodium, an extremely important source of salt/sodium in the diets of people in the Caribbean and Central and South America. Specific to the Consortium, as well as the social marketing projects, is the engagement of supermarkets and food importers.

Mary L’Abbé reiterated the advancements made with baselines for salt/sodium content in packaged foods in 12 food categories. Sir Trevor Hassel called for governments to commit wholeheartedly to addressing hypertension and NCDs as they are development issues. Carol Bryant emphasized the efforts of the social marketing teams in the four countries, describing

their intention to focus initially on the discretionary use of salt/sodium by young mothers with children in primary school.

Ms. Hildred Simpson, Permanent Secretary for health in Antigua and Barbuda, closed the meeting, applauding and extending support to the efforts to reduce NCDs. The ministry of health will be assisting and the ministry of education should be involved.

APPENDIX 1: List of Participants at the 4 th Meeting of the SaltSmart Consortium 17-18 September 2015 Caribbean (Antigua & Barbuda, Jolly Beach Resort Hotel)

Blanco-Metzler, Adriana Kidd, Shawna Researcher, Corporate communications and consumer Instituto Costarricense de investigación y services manager, Nestle Enseñanza en Nutrición y Salud (INCIENSA ) Jamaica Tres Rios, San José, Costa Rica E-mail : [email protected] E-mail: [email protected] Kipreos, Luisa Fretes Centurión, Gabriela Department of Eating and Nutrition Nutritionist and Coordinator Ministry of Health, Chile Gabi’s Cooking Workshops E-mail: [email protected] Paraguay E-mail: [email protected] L’Abbe, Mary Professor and Chair of Nutritional Sciences Getrouw, Anne University of Toronto Nutritionist Ontario, Canada Bureau of Public Health E-mail: [email protected] Suriname E-mail: [email protected] Linders, Hubert Information Advisor Hassell, Trevor Consumers International President Santiago, Chile Healthy Caribbean Coalition Email: [email protected] Bridgetown, Barbados E-mail: [email protected] Mcghie, Diana Global Strategies & Programs Hernandez, Elizabeth American Heart Association Health and Nutrition Researcher Washington, D.C. National Institute of Public Health E-mail: [email protected] Mexico City, Mexico E-mail: [email protected] Rabanal, Maria Rosa Scientific, Regulatory Affairs and Nutrition Hutton, Maisha Manager for Southern Cone and H&W LA Executive Director Mondelez Healthy Caribbean Coalition Buenos Aires, Argentina Bridgetown, Barbados E-mail: [email protected] E-mail: [email protected]

USF WHO Collaborating Centre on Social Marketing for Social Change: Linda Whiteford [email protected] Carol Bryant Co-Director [email protected] USF WHO Collaborating Center Co-Director USF WHO Collaborating Center Tampa, Florida WHO/PAHO:

Sinead Duane Tomo Kanda [email protected] Advisor Fellow Bridgetown, Barbados USF WHO Collaborating Center E-mail: [email protected]

Dana Ketcher [email protected] WHO/PAHO Secretariat: Doctoral student USF WHO Collaborating Center Branka Legetic Regional Advisor James Lindenberger Chronic Disease Prevention and Control, [email protected] WHO/PAHO The Social Marketing Group Washington, DC University of South Florida E-Mail: [email protected]

Mahmooda Pasha Barbara Legowski [email protected] Temporary Advisor Associate Director Ottawa, Canada USF WHO Collaborating Center E-mail: [email protected]

Robin Mowson Consultant Washington, D.C. E-mail: [email protected]

APPENDIX 2: Meeting Agenda

SALTSMART CONSORTIUM

The Multi-stakeholders Committed to Reducing the Overconsumption of Dietary Salt/sodium in the Americas

Implementing social marketing to change the social norm on salt/sodium consumption 4th Meeting 17-18 September 2015 (Jolly Beach Resort Hotel, Antigua & Barbuda)

Background

The following goals attracted participation in the Consortium:

• Create a positive environment that enables consumers to choose low/no salt/sodium food products;

• Acknowledge the contributions and achievements of the Consortium;

• Share best practices and lessons learned, both positive and negative, on an open and safe platform; and

• Support country initiatives to reduce the overconsumption of salt/sodium.

The Consortium has had three meetings. At the first, held in August 2012 in WDC, the Consortium discussed terms of reference and agreed to a draft work plan. At its second meeting in June 2013 in WDC, the Consortium accepted a Strategic Plan (2013-2018) and reached consensus to priorize two areas of work in its Plan: social marketing and harmonizing salt/sodium reduction targets for the Region. The Consortium then began discussing a way forward with social marketing and agreed to participate in developing and piloting a social marketing campaign. Its first exercise was drafting a creative brief that would serve an advertising agency in designing social marketing messages, based on country formative research, aiming to build consumer demand for low/no salt/sodium products.

This Meeting

This meeting of the Consortium is returning to its social marketing priority. It coincides with a social marketing project rolling out in the Caribbean in four countries – Barbados, Jamaica, Antigua and Barbuda, and St Vincent and Grenadiers. They intend to build a new social norm for lower salt/sodium intake. The project is a collaborative initiative involving PAHO, the American Heart Association, the Healthy Caribbean Coalition and the WHO Collaborating Centre on Social Marketing at the University of South Florida (USF).

The preparatory phase of a social marketing campaign is underway with multi sector teams in the four countries participating in on-line training assisted by the USF WHO CC on Social Marketing.

At this meeting, Consortium members will achieve the following objectives:

1. Present their respective advances with uptake and dissemination of regional targets, and the initial steps for monitoring uptake 2. Gain an understanding of the consumer research performed by the American Heart Association

3. Gain an understanding of social marketing for public health and in depth knowledge on the project in the Caribbean 4. Hear the progress made to date in the Caribbean countries 5. Discuss and agree to the roles for Consortium members that can advance the current social marketing project in the Caribbean

AGENDA

Thursday 17 September

8:30 – 9:00 Registration

9:00 – 9:15 Welcome

9:15 – 9:30 Introduction of meeting objectives, agenda and Branka Legetic participants

Advances with regional targets – identifying Chair: Hubert Linders baseline nutrient contents for monitoring

9:30 – 9:40 LATINFOODS database Adriana Blanco-Metzler

9:40 – 9:50 Participation in the George Institute Global Elizabeth Hernández Food and Beverage Information Database

9:50 – 10:10 First results of baseline survey on salt/sodium Mary Labbe levels in 12 food groups with regional targets

10:10 – 10:30 Questions and comments

10:30 – 11:00 Break

Advances with regional targets – uptake and Chair: Mary Labbe dissemination

11:00 – 11:30 [food companies]

11:30 – 12:00 Civil society InterAmerican Heart Foundation, Consumers International, Healthy Caribbean Coalition

12:00 – 12:30 Questions and comments

12:30 – 14:00 Lunch

14:00 – 14:20 Consumers research results American Heart Association

14:20 – 14:40 Social marketing to change the social norm USF WHO CC on Social on salt/sodium consumption Marketing [Jim Lindenberger]

14:40 – 15:00 Questions and comments

15:00 – 15:30 Country progress to date Barbados, Jamaica

15:30 – 15:50 Break

15:50 – 16:20 Country progress cont’d Antigua & Barbuda, and St Vincent & Grenadiers

16:20 – 16:40 Questions and comments

16:40 Adjournment

Friday 18 September

9:00 – 9:10 Review of day 1, objectives for day 2 Branka Legetic

Contribution of Consortium members to the Chair: Trevor Hassel social marketing implementation plans

9:10 – 11:00 Plenary discussion

1)what can you or your organization do to help mothers of young children lower the discretionary use of salt (i.e., make spice mixes and sauces with less salt, add less salt, select low salt options);

2) what are the barriers to discretionary use and what can you or your organization do to lower these barriers and make it easier for women to change;

3) how could you and your organization promote messages or sponsor activities to encourage mothers to use less salt at home; and

4) what partners could you mobilize to help; and

if time permits

5) what could you and your organization do to make low salt options more accessible in schools and supermarkets?

11:00 – 12:30 Break

12:30 – 13:00 Closing remarks Permanent Secretary, Antigua and Barbuda Ministry of Health

13:00 Adjournment

APPENDIX 3: Social Marketing Country Teams ANTIGUA AND BARBUDA Juanita James [email protected] President The Antigua & Barbuda Diabetes Association

Almarie Robert-Coates [email protected] Family Nurse Practitioner Ministry of Health

Lorren Davis [email protected] Food and Nutrition Teacher

BARBADOS Lisa Bayley [email protected] Representative of Media

Denise Carter Taylor [email protected] Senior Health Promotion Officer Ministry of Health

Sheena Warner-Edwards [email protected] Ministry of Health

JAMAICA Rosemarie Wright-Pascoe [email protected] Professor of Medicine University of West Indies

Rainford Wilks [email protected] Director, TMRI University of West Indies

Camelia Thompson [email protected] Manager of Health Promotion

ST VINCENT AND THE GRENADINES Beverly Liverpool [email protected] NCD Focal Point Ministry of Health

Patsy Wyllie [email protected] Chief Health Promotion Officer Ministry of Health

Wendy Michael [email protected] Nutrition Unit Ministry of Health