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Problems definition

Discuss about the global health and sustainability by designing an evaluation of a global health initiative.

The increasing number of the processed food, changing lifestyle, transforming the dietary patterns, rapid urbanization has led to the increased amount of consumption of salt. The processed food is becoming increasing affordable and their availability has increased. The people all around the world are consuming energy-rich food that is high in salt, sugar, trans fat, saturated fats. The major and the primary source of sodium is salt and sodium is found to be associated with the increased risk of the stroke and heart diseases and hypertension. The shift in the eating patterns and the consumption of the less amount of the dietary fibre, vegetables and less amount of fruit. These are mainly considered as the main contents of the healthy diet. Vegetables and the fruits contain potassium and contributes majorly to the reduction of blood pressure (Nutbeam, 1998). The presence of salt in the diet comes from the processed food, due to the two major factors. Either the food is consumed in large amounts or the food is taken frequently in large amount. Salt is also added during the cooking process. The WHO guidelines say that there must be a threshold on the intake of the potassium and sodium. The guidelines set by the WHO also measures in improving the diet and also acts to reduce the spread of the non-communicable diseases in the children and adults (World Health Organization Collaborating Centre for Population Salt Reduction, 2018). The study is based on the identification of a global initiative related to the reduction in the sodium consumption. The study also involves the planning of the evaluation of the initiative

The global health problem is evident in almost all the countries worldwide and the problem is associated with the people eating too much salt. The problem due to the consumption of too much salt can potentially lead to high blood pressure. which can lead to problems like stroke and heart diseases. Thus, in order to reduce the amount of salt consumed, the governments of different countries have developed the national salt reduction initiatives.

An average person in the United Kingdom is considered to eat about 8.1 grams of salt per day. The value is found to get reduced by 15 percent in the last decade, due to the product reformulation, where it has been found that the food industry has gradually reduced the usage of salt in food.  However, the population of UK is still in taking about 6grams of salt and due to this, there is an increased risk of the UK people that are suffering in the later part of their life (Christopher & Wallace, 2014).  

Description of the initiative

Thus a comprehensive strategy was taken up by the Food Standards agency effectively targeting the UK people. The strategic targets are as follows:

  • Reduction in the intake of the salt to 6 grams in the average population
  • Reduction in the intake of the saturated fat intake to about 11 percent of the food energy.
  • To provide help to the consumers so that they can maintain an energy balance.
  • To promote the provision and plan of nutritional labelling (He, Brinsden & MacGregor, 2014).

Reduction in the salt consumption by the Food Standards Agency (FSA) was made a type of public health priority in the early 2000’s. The Food Standards Agency was an independent body at that time and was entirely responsible for the action on salt and nutrition. The FSA laid out plans and targets for about 80 food categories and mentioned that the food industry must voluntarily adhere to the same. The strategies are in complete coordination and are in line with the public awareness campaign like the “is your food full of it”, “check the label”, “sid the slug”. All the members of the food industry were motivated and encouraged to work accordingly so that the salt targets can be achieved within the acceptable timeframe (Millett et al., 2012). New and low targets are set within after a couple of years and 2012 was set as the deadline in which the targets are to be achieved. An approach of resetting the targets were taken up in order to achieve the United Kingdom recommended policy of 6 grams per day within 2015. In the year 2011, when a new coalition government was formed, the responsibility of FSA was given to the Department of Health. The new coalition government set up the Public Health Responsibility Deal. In the year 2014, the Department of Health framed new salt targets which are to be achieved by the end of the year 2017. The monitoring of the food data did not take place within the within this time frame and in the year 2016 the Responsibility Deal ceased to exist. The responsibility of salt reduction again switched hands and now the responsibility went to Public Health England (actiononsalt.org, 2018).


The salt reduction strategies are considered to be a real success in the United Kingdom and the several food products are found to reduce their salt content by a big margin in comparison to a decade ago. The out of the home sector was found to be left out of the whole salt reduction programme and it was later found that they were wrongly left out of rest of the food industry. The catering industry was left out of the salt reduction strategy and many of the food catering industry still believed in the adding salt increases the seasoning and flavour (Shankar et al., 2013). This is however wrong because a lot of research confirmed the bad effects on health due to the excess of salt in the food items. The data showed that one in every six meals that are consumed out of the home, it is therefore important to consider to that the catering sector falls in line with the reduction of salt in the meals. In order to engage with the catering sector, the Department of Health set the targets for the serving salt in food. The targets were meant for the 10 of the most popular dishes that are sold in the UK restaurants along with the food items for the kids (actiononsalt.org, 2018).

Resource mobilisation

It has been seen that the United Kingdom is leading the way in salt reduction and many countries contributed towards the implementation of the same. The initiative can be used to effectively reformulate the food by the caterers, manufacturers and the retailers; the initiative can be used to educate the consumers and providing the information to the consumers; the initiative can be used for the improved nutritional labelling so that informed choices can be made.

Figure 1: Model showing the inputs, outputs and outcomes of the initiative

The potential barriers- 

  • The increased production of the more and more processed food along with the transforming dietary pattern, changing lifestyle, rapid urbanization. Highly processed food is highly available and they are increasingly becoming affordable and available. People all around the world are constantly consuming energy-rich food that contains high quantities of salt, sugar, trans fats, saturated fats. Salt is primarily considered as the most basic source of sodium and due to the increased consumption of the sodium, there are increased chances of stroke, high rate of heart diseases and hypertension (World Health Organization, 2018). While it is important to note that the eating pattern within the people shift and there is also another reason that people consume less amount of dietary fibre like the whole grains which are considered as the main ingredients of the healthy diet. While it is important to note that the vegetable and the fruits contribute to the reduction in the blood pressure. Salt in the diet comes from the processed food items. The reason is either people consume food that has high salt content (instant noodles, salty snack foods, cheese, salami, ham, meat like bacon and ready meals) or the food is consumed in large amounts like the processed cereal products and bread. Salt is also added to the food during the process of cooking (stock cubes and bouillon) or at the table (table salt, fish sauce, soy sauce) (World Health Organization, 2018).
  • The other types of active barriers include the barriers that include the food industry and the resistance of the consumers towards the state interference in the freedom to consumers for the consumption of the unhealthy products.
  • There are political barriers, like the actions of the state is not held responsible with respect to the mitigation of the health risks and the risks associated with the public health (Reeve & Magnusson, 2015).
  • The other kinds of barriers with respect to the salt reduction are: preference for the soup; increased preference for the salt-preserved dishes; lack of the taste; lack of the knowledge of the people when it comes to strategies of salt reduction; complicated cooking process; limited number of the choices when eating at the restaurants (Dunford et al., 2012).

The enablers

  • The report published by the Scientific Committee on Nutrition (SACN) emphasized on the salt and the health and it recommended that there is a need to reduce the intake of salt among the general population and the intake level should be 6 grams per day.
  • A draft model was published by FSA and this examined the effects that are related to the negative effect of the salt reduction and the content of salt in food and the overall population which is consuming the salt (Food Standards Agency, 2018).
  • A meeting was held with the salt stakeholders along with the parliamentary undersecretary and it was requested that there is an urgent need to reduce the salt in food.
  • Department of Health (DH) went on to publish a report on making healthy choices and easier and choosing health (Food Standards Agency, 2018).
  • The DH, as well as the FSA, wrote to the individual food organizations regarding the reduction of salt in food items and this led to the finalising and publishing the final model.
  • FSA strategic plan was published in the year 2005-10 and a target was set for the reduction of the consumption of salt by 6 grams per day and for this purpose FSA set a limit on salt content in food categories.
  • A series of the short TV commercials were organized and it resulted into spreading the awareness of the key messages for the reduction of salt consumption.
  • Along with FSA, the British Meat Processors Association published a small guidance. This guidance acted as a document for the medium and the small-sized businesses for the salt reduction (Food Standards Agency, 2018).

Strategies to identify the enablers and the barriers

Reformulation of the processed food items- in the UK and the 75 to 80 percent of the population consumes about 80 percent of the processed food item. This has resulted in the reformulation of the food item and this led to the to an increase in the salt reduction strategy in the UK. Thus, resulted in a salt model and it was published in the year 2003. This was formulated by organizing discussions with the food industry about the reduction of the salt content in a food item and also to emphasize on the reduction of the salt consumption by 6 grams per day on average. The model developed by FSA showed the different food items contributed to the UK salt intakes and to the average level of salt in each category of the food items (Collins et al., 2014). It has been found that the model developed by FSA contained the categories of the food item that provided the most amount of the salt intake into the UK diet. The salt model includes that in order to reach the target level of 6 grams per day, it will require a concerted and a substantial effort by the food service outlets, retailers and manufacturers. FSA started to set the targets of the level of salt in food items in food items. The product surveys that were conducted by the NGOs and the consumer groups resulted into identifying the companies with the higher levels of the salt intake into the products and this put some companies at a commercial disadvantage (He, Brinsden & MacGregor, 2014).

Front of the pack labelling- between the year 2004 to 2010, the FSA worked along with the other stakeholders and in order to explore the ways of providing the nutritional information on the front part of the packs of the food. This will enable the consumers to make the healthy choices. In the year 2006, FSA recommends a principle that is based on the nutritional labelling in the form of traffic lights and this will help the consumers stay healthy. This kind of labels are called the FOP labels and labels indicate the salt, sugar and fat in the product. The labels from some companies contain the information that is based on the traffic lights and they indicate the level of nutrients as low, medium and high. A large number of the food retailers in the UK introduced the FOP labels. The various FOP labels that were used in the food industry, differed only in the interpretative elements that are used within the products. The FSA encouraged all the drink and food businesses to move into labelling format such that it exhibits all the vitals elements (Christopher & Wallace, 2014).

Public awareness campaign- the work of reformation was augmented by the awareness campaign of FSA and it aims to improve the consumer’s knowledge by establishing a link between the health and salt.  A campaign was conducted by the in four phases and it involved the information that is published on the FSA's website, digital advertising, experimental activity at the supermarkets, materials and leaflets for the consumers, poster advertisements, press, radio, television. The public awareness campaign included the main target group included women that are aged 25 to 65 years of age. When it comes to health and food, the women in the household are considered. During the 2nd and the 3rd phases of the campaign, some of the NGOs and some of the food companies carried out work so that campaign messages can be disseminated to the hard reach groups. This included the examples of the practical and the educational programmes like the grocery shop tours, tasting sessions, cooking classes. The target groups included the residents, housing association staff Sikh and the Hindu population, young parents, inner-city communities, minority ethnic groups, black ethnic groups (Millett et al., 2012).

Other activities of FSA that contributed to the reduction of salt intake in the UK- for the reduction of the levels of salt in food, FSA was working with the manufacturing organizations, retailers as well as the catering sector. A framework was devised which was flexible and it highlighted the four areas through which food that is provided and eaten away from home can be taken into action. This approach was later found to be successful because about 45 companies were willing to commit and change the quantity of salt in the food which is eaten away from home. This also included taking actions that are based on the proper menu planning, reviewing the kitchen practices and the lowering the level of salt in food items. All these were done so that the customers were able to make informed choices of their meal (Shankar et al., 2013).

Evaluation of the initiative using a qualitative study design

Objectives

 Reduction of salt is one of the most cost-effective interventions for the purpose of preventing the occurrence of the non-communicable diseases. However, there is a lack of national studies that emphasize the condition in Australia. The objective of the study is to examine the current levels of salt intake and thus the current levels were estimated (Land et al., 2018).

Design

Random effects meta-analysis data from the published studies (31) and one form the unpublished study were taken into account that reported on the consumption of sodium by the Australian adults. The data were collected on the 24-hour basis urine collection or the questionnaires.

Setting

Australia

Subjects

31 published studies and one unpublished study that took into account the 16,836 individuals were identified.

Results

The mean weighted consumption of salt was estimated from the 24-hour urine collection was 8.70 gram per day. The best intake of salt was found to be 9.6 gram per day. The mean weighted intake was found to be 10.1gram per day for both men and women. The Mean weighted consumption was found to be 6.49 gram per day when measured along with another diet. When the assessments were done through the questionnaires, it was found that the daily intake of salt is 6.73 gram per day (Land et al., 2018).

Conclusion

The intake of salt in Australia exceeds the level that is recommended by the maximum of 5 grams per day and it does not show any declining trend. The self-reporting method of salt intake substantially underestimate the levels of consumption (Land et al., 2018).

  • Reduction in the cases of the stroke and heart diseases (Benjamin et al., 2016).
  • Reduction in the deaths of the individuals from the cardiovascular diseases that are reported every year (He, Li & MacGregor, 2013).
  • Reduction in the purchase of the restaurant and processed food items (Jacobson, Havas & McCarter, 2013).

The outcomes will be assessed in the following ways:

  • Educating the consumers
  • Taxing the food items that contain high levels of salt (Mytton, Clarke & Rayner, 2012).
  • Labelling schemes on the front part of the packaging.
  • Targeting the food items that contain the high amounts of salt.
  • Reformulation of the food products by engaging with the food manufacturing industries (Jaenke et al., 2017).

Strategies that would be used for the dissemination of the outcomes of the public health initiative

  • Conducting the web series on the forums for the dissemination of the information.
  • In order to reduce the levels of sodium in food items, instructional videos can be produced.
  • Establishment of the learning communities that will work in collaboration with the health practitioners, health partners and also with the food industry experts.

Conclusion

Thus, from the above study, it can be concluded that there is an excessive salt intake is a major public health issue that leads to diseases like the cardiovascular diseases and stroke. It is recommended by WHO that the daily intake of salt must not exceed the 2 grams and consume the excess amounts of salt has resulted in several diseases. The strategy that was devised by the UK FSA emphasize the reduction of salt consumption on a daily basis and this was done through an array of methods. This effectively led to the reduction in salt consumption on a daily basis.

References

actiononsalt.org. (2018). Retrieved from https://www.actiononsalt.org.uk/uk%20salt%20reduction%20programme/145617.html/#

Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., ... & Jiménez, M. C. (2017). Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation, 135(10), e146-e603. DOI: 10.1161/CIR.0000000000000485

Christopher, D., & Wallace, C. A. (2014). The food safety impact of salt and sodium reduction initiatives. Perspectives in public health, 134(4), 216-224. DOI: https://doi.org/10.1177/1757913914536701

Collins, M., Mason, H., O’Flaherty, M., Guzman-Castillo, M., Critchley, J., & Capewell, S. (2014). An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. Value in Health, 17(5), 517-524. DOI: https://doi.org/10.1016/j.jval.2014.03.1722

Dunford, E., Webster, J., Woodward, M., Czernichow, S., Yuan, W. L., Jenner, K., ... & Neal, B. (2012). The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction. Canadian Medical Association Journal, 184(9), 1023-1028. DOI: https://doi.org/10.1503/cmaj.111895

Food Standards Agency. (2018). Food Standards Agency - Salt timeline of key events. Retrieved from https://webarchive.nationalarchives.gov.uk/20080906193456/https://www.food.gov.uk/healthiereating/salt/salttimeline

He, F. J., Brinsden, H. C., & MacGregor, G. A. (2014). Salt reduction in the United Kingdom: a successful experiment in public health. Journal of human hypertension, 28(6), 345. DOI: 10.1038/jhh.2013.105

He, F. J., Li, J., & MacGregor, G. A. (2013). Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. Bmj, 346, f1325. DOI: https://doi.org/10.1136/bmj.f1325

Jacobson, M. F., Havas, S., & McCarter, R. (2013). Changes in sodium levels in processed and restaurant foods, 2005 to 2011. JAMA internal medicine, 173(14), 1285-1291. DOI: 10.1001/jamainternmed.2013.6154

Jaenke, R., Barzi, F., McMahon, E., Webster, J., & Brimblecombe, J. (2017). Consumer acceptance of reformulated food products: A systematic review and meta-analysis of salt-reduced foods. Critical reviews in food science and nutrition, 57(16), 3357-3372. DOI: https://doi.org/10.1080/10408398.2015.1118009

Land, M. A., Neal, B. C., Johnson, C., Nowson, C. A., Margerison, C., & Petersen, K. S. (2018). Salt consumption by Australian adults: a systematic review and meta-analysis. The Medical Journal of Australia, 208(2), 75-81. DOI: 10.5694/mja17.00394

Millett, C., Laverty, A. A., Stylianou, N., Bibbins-Domingo, K., & Pape, U. J. (2012). Impacts of a national strategy to reduce population salt intake in England: serial cross sectional study. PLoS One, 7(1), e29836. DOI: 10.1371/journal.pone.0029836

Mytton, O. T., Clarke, D., & Rayner, M. (2012). Taxing unhealthy food and drinks to improve health. BMJ: British Medical Journal (Online), 344. DOI: 10.1136/bmj.e2931

Nutbeam, D. (1998). Evaluating health promotion—progress, problems and solutions. Health promotion international, 13(1), 27-44. DOI: https://doi.org/10.1093/heapro/13.1.27

Reeve, B., & Magnusson, R. (2015). Reprint of: Food reformulation and the (neo)-liberal state: new strategies for strengthening voluntary salt reduction programs in the UK and USA. Public health, 129(8), 1061-1073. DOI: https://doi.org/10.1016/j.puhe.2015.04.021

Shankar, B., Brambila?Macias, J., Traill, B., Mazzocchi, M., & Capacci, S. (2013). An evaluation of the UK Food Standards Agency's salt campaign. Health Economics, 22(2), 243-250. DOI: https://doi.org/10.1002/hec.2772

World Health Organization Collaborating Centre for Population Salt Reduction. (2018). Retrieved from https://www.georgeinstitute.org.au/projects/world-health-organization-collaborating-centre-for-population-salt-reduction-who-cc-salt

World Health Organization. (2018). Salt reduction. Retrieved from https://www.who.int/en/news-room/fact-sheets/detail/salt-reduction

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