1 Salt-Smart Americas: A Guide for Country-Level Action Also published in Spanish (2013) with the title: La reducción de la sal en las Américas: una guía para la acción en los países ISBN 978-75-31769-3 PAHO HQ Library Cataloguing-in-Publication Data ***************************************************************************************************************************************************** Pan American Health Organization. Salt-Smart Americas: A Guide for Country-Level Action. Washington, DC : PAHO, 2013. 1. Sodium Chloride, Dietary. 2. Cardiovascular Disease. 3. Behavior. 4. Food Industry. 5. Americas. I. Title. ISBN 978-92-75-11769-9 (NLM Classifi cation: WB 424) The Pan American Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and inquiries should be addressed to the Department of Knowledge Management and Commu- nications (KMC), Pan American Health Organization, Washington, D.C., U.S.A. 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Table of Contents Preface ix Acknowledgements x Recommendations for the Americas 1 Policy Statement: Preventing Cardiovascular Disease in the Americas by Reducing Dietary Salt Intake Population-Wide 3 Policy Goal 4 Audience 4 Rationale 4 Recommendations for Policy and Action 4 To National Governments 4 To Nongovernmental Organizations, Health Care Organizations, Associations of Health Professionals 5 To the Food Industry 5 To the Pan American Health Organization 5 Background 6 Prevalence of Hypertension 6 Non-Optimal Blood Pressure, Health and Salt 6 Population-Wide Salt Reduction is Cost-Effective and Equitable 6 Fortifi cation Alternatives 7 References 8 PAHO/WHO Regional Expert Group for Cardiovascular Disease Prevention Through Population-Wide Dietary Salt Reduction. Final Report November 2011 9 Executive Summary 10 Key Messages 10 Recommendations 11 Introduction 15 The Consumption and Overconsumption of Salt 15 High Salt Intake Is Unsafe 15 Lowering Salt Intake Is Cost-effective and Cost-saving 16 WHO Platforms for Dietary Salt Reduction 16 WHO Population Salt Reduction Strategy 16 The PAHO Initiative – Cardiovascular Disease Prevention through Population-wide Dietary Salt Reduction 17 Background 17 The Expert Group and its Sub-groups 18 Purpose of this Report 19 Tools, Resources and Achievements 19 Advocacy and Communication 19 Surveillance 20 Food Industry Engagement 21 Synchronizing Salt Iodization and Salt Reduction Programs 23 Economic Studies on the Cost-effectiveness and Cost-savings of Population Level Dietary Salt Reduction 24 Status of Action in the Americas 24 Country-specifi c Summaries 24 Food Categories for which Salt Content Is Being Reduced 28 Lessons Learned So Far 29 Challenges 30 Momentum and Potential in the Region 31 References 32 Appendix 1: Organizations that Have Endorsed the Policy Statement as of September 2011 34 iv Appendix 2: Dissemination Activities 36 Appendix 3: Country-specifi c Targets and Timelines 37 Population Awareness-Building 39 Applying a Social Marketing Framework to Salt Reduction 41 Situation Analysis 42 Literature Review and Research Findings 43 Target Audience 43 Audience Analysis 44 Overview of Supply Side 45 Demand Side/Communication Goals and Objectives 45 Marketing Mix Strategies 46 Monitoring and Evaluation Plan 51 Work Plan and Timeline 52 Budget/Funding Sources 52 Postscript: How Can Social Marketing Strengthen Current Efforts? 53 Appendix 1: Reviews, Outlines and Forms 54 Global Literature Review Synthesis 54 Social Marketing Plan Outline 55 Marketing Mix Planning Tool 57 Creative Brief Form 57 Bravo Criteria Checklist 58 Implementation Plan Template 58 Monitoring and Evaluation of Salt Consumption, Sources of Salt and Knowledge and Behaviors 61 Protocol For Population Level Sodium Determination In 24-Hour Urine Samples 63 Section 1: Introduction 64 Overview of the PAHO/WHO Protocol for Population Level Sodium Determination in 24-Hour Urine Samples 64 Rationale for Population Level Sodium Determination in 24-Hour Urine Samples 64 Section 2: Field Protocol 66 Overview of the Field Protocol 66 Planning and Conducting a 24-Hour Urine Collection Study 66 Selecting the Sample 67 Implementation Plan 69 Applying for Ethical Approval 70 Timeframes and Data Collection Considerations 70 Adapting the PAHO/WHO Protocol for Sodium Determination in 24-Hour Urine Samples 70 Pilot Testing 71 Section 3: Data Collection Guide 71 Instructions for Field Staff, Equipment and Analytic Methods 71 Guide to Physical Measurements 72 Measuring Blood Pressure and Heart Rate 73 Measuring Height 74 Measuring Weight 74 Measuring Waist Circumference 75 Measuring Hip Circumference 75 Section 4: Questionnaire on Knowledge, Attitudes, and Behavior toward Dietary Salt 76 v Section 5: Detailed Instructions for Participants in 24-Hour Urine Collection 77 Section 6: Household Salt Collection and Iodine Determination 78 Section 7: Use of Spot Urine to Estimate 24-Hour Excretion of Sodium, Potassium and Iodine 78 Section 8: Dataset for Health Economic Analysis 79 References 79 PAHO/WHO Sodium Detection in 24-Hour Urine Samples Questionnaire 82 A Review of Methods to Determine the Main Sources of Salt in the Diet 91 Section 1: Introduction 92 Section 2: Food Consumption Surveys 92 Overview 92 Methods that Provide Direct or Primary Data on Food Consumption 93 Using Indirect or Secondary Data Sources 95 Attaching Questions or Modules to Existing Chronic Noncommunicable Disease Risk Factor Surveys 96 Section 3: Sodium Content of Foods 97 Overview 97 Methods that Provide Direct or Primary Data 97 Food Composition Tables and Databases from Selected Countries and Regions 97 Using Indirect or Secondary Data Sources 98 Section 4: Salt Added at the Table and during Cooking 99 Qualitative Methods 99 Direct Quantitative Methods 99 Indirect “Subtraction” Method 100 Secondary Sources 100 Section 5: Culturally or Regionally-specifi c High-sodium Foods 100 Section 6: Recommendations 100 Determining Baseline Data on the Major Contributors to Salt Intake 101 Establishing and Maintaining Food Composition Databases and Tables 101 Deciding on Targets and Interventions 102 Monitoring and Evaluation 102 References 103 Appendix 1: Examples from the Region 104 Protocol for the Survey on Knowledge, Attitudes and Behavior toward Dietary Salt and Health 109 Introduction 110 Justifi cation 110 Main Objective 110 Hypothesis 110 Methodology and Data Analysis 110 References 111 Appendix 1: Questionnaire on Knowledge, Attitudes, and Behavior toward Dietary Salt and Health 112 Optimizing Salt and Iodine Intake 115 White Paper on Improving Public Health by Optimizing Salt and Iodine Intakes 117 Background 118 The Common Goal 119 A Framework for Collaborative Action 119 References 120 vi Improving Public Health in the Americas by Optimizing Sodium and Iodine Intakes 121 Key Messages 122 Background 122 Presentation Summaries 123 Meeting Outcomes 129 Conclusions and Next Steps 130 References 131 Appendix 1: Meeting Participants and Contributors to the Position Document 133 Targets Setting and Voluntary Industry Engagement 137 A Guide for Setting Targets and Timelines to Reduce the Salt Content of Food 139 Key Messages 140 Introduction 140 Purpose of the Guide 140 Step 1 – Secure the National Strategy to Reduce Dietary Salt 141 Step 2 – Prepare Data 144 Step 3 – Identify the Key Stakeholders 146 Step 4 – Plan the Meetings 148 Step 5 – Monitor Performance 148 Dealing with Technical Issues, Controversies, Barriers 149 Appendix 1: Table 1 - Targets and Timelines for Food Categories in Common in Argentina, Brazil, Canada, Chile and the National Salt Reduction Initiative in the United States (As of January 2013) 151 Appendix 2: Links to National Targets and Timelines Including Industry Commitments Made Public 156 Appendix 3: Pros and Cons for Types of Targets that Can Be Set 157 vii Preface The Region of the Americas has taken