© World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@ who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non- commercial distribution– should be addressed to WHO Press through the WHO website (http://www. who.int/about/licensing/copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Graphic design by Studio FFFOG. Printed by the WHO Document Production Services, Geneva, Switzerland. WHO/NMH/PND/16.4
4AN ASSALT ON PUBLIC HEALTH: THE HIDDEN COST OF SALT “Salt intake is too high in 181 of 187 countries around the world” The Washington Post (1) “Salt: the single most harmful substance in food” The Sydney Morning Herald (2) “Salt reduction lowers cardiovascular risk” The Lancet (3) “Menos sal, mas vida” (Less salt, more life) El Litoral (4) These are just a handful of the headlines from the past 18 months when global media have tried again and again to draw attention to the health dangers of eating too much salt. People worldwide consume significantly more salt than they should. Excessive salt consumption is linked to a number of health risks which cause millions of premature deaths annually, such as high blood pressure which accounts for an estimated 9.4 million deaths each year (5). Controlling the threat that salt poses to public health is a challenge facing developed and developing countries alike. The easiest and most cost-effective way of addressing the threat is simple: reduce the amount of salt people eat. Lowering salt consumption is a practical action which can save lives, prevent related diseases and reduce health-care costs for governments and individuals (6-8). Yet the battle against salt has shown that this is easier said than done. The World Health Organization (WHO) recommends a level of salt intake that is less than 5g per day for adults and even less for children (9). Figure 1 shows that salt intake is estimated to be well above the recommended level in almost every country (10). 5The overall global target is a 30% reduction by 2025 in global average population salt consumption. This is the only nutrition-specific target and a core component of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013−2020, which aims to achieve a 25% reduction in premature mortality from avoidable noncommunicable diseases (NCDs) by 2025 (6). Despite strong evidence of the health benefits of salt reduction, policy-makers face many difficulties when translating this evidence into effective public policy. The role of WHO is to bridge this gap, yet a recent article in The Lancet highlighted the organization’s failure to help countries to implement the guidelines it produces (11). In response to this, WHO has reviewed examples of successful salt reduction policies from around the world and has identified a common set of best practices. Successes in countries such as Argentina, Kuwait and the United Kingdom have shown what works, and WHO has collected a range of technical models and interventions from different settings. This evidence base was used to create the SHAKE package. 6“Governments will have the tools to start reducing the amount of salt consumed by their citizens” The SHAKE package is a set of common-sense, evidence-backed policy options and examples which support governments to lower population salt consumption. The options have been chosen because there is evidence that they work as a complete package, are inexpensive as a public health investment, and because WHO has experience in helping countries implement them to the highest standards. Figure 1: Mean sodium intake in persons aged 20 years and over, comparable estimates, 2010 7Mean sodium intake in persons (g/day) <2.75 2.75 - 3.49 3.5 - 4.24 ≥4.25 Data not available Not applicable The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data Source: Powles J et al BMJ Open 2013;3:e003733 World Health Organization. 0 850 1,700 3,400 kilometers 8If the SHAKE package was implemented in every country as a comprehensive package, research indicates that it could save millions of lives per year and dramatically reduce the burden of NCDs on health systems (12). Few countries are fully embracing all of these salt reduction policies and many have taken no action at all to reduce population salt consumption (13). It is hoped that, with these policies and the accompanying resources, governments will have the tools to start reducing the amount of salt consumed by their citizens and to prevent some of the millions of premature deaths caused by cardiovascular diseases. “LOWERING SALT CONSUMPTION IS A PRACTICAL ACTION WHICH CAN SAVE LIVES” 10 THE SHAKE PACKAGE FOR SALT REDUCTION The SHAKE package contains a general framework for the overarching elements needed to create a successful salt reduction strategy: political commitment, programme leadership, partnerships and advocacy (see Annex 1). SHAKE looks at the role of each of these within the main activity areas of a successful national salt reduction strategy, based on the SHAKE acronym: SHAKE THE SALT HABIT 11 SURVEILLANCE MEASURE AND MONITOR SALT USE HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT ADOPT STANDARDS FOR LABELLING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING 12 WHO offers a variety of tools for the monitoring and evaluation of salt reduction SURVEILLANCE MEASURE AND MONITOR SALT USE Why it matters Data from monitoring are necessary to ensure the success of salt reduction interventions. It is important to measure how much salt the population is consuming. This information can be used to show leaders of government and civil society why salt reduction is important and can help them to allocate resources where they will be most effective. It is also essential to identify the dietary sources of salt and to collect information on consumer behaviour so that effective interventions can be designed, implemented and evaluated. What needs to be done There are three key stages in monitoring a salt reduction programme: 1. Measure and monitor population salt consumption patterns. 2. Measure and monitor the sodium content of food. 3. Monitor and evaluate the impact of the salt reduction programme. 13 Within the SHAKE package, WHO offers a variety of tools for monitoring and evaluating salt reduction interventions, including various methods for qualitative and quantitative assessment of a policy, as well as its cost- effectiveness. In order to maximize the quality of monitoring, a range of stakeholders need to be involved. Governments must play a leading role in monitoring and evaluating policies aimed at reducing salt intake at the population level, as well as in allocating funds to support these activities. Nongovernmental organizations, civil society, academia and health-care professionals have significant roles to play in monitoring the implementation of any new policies. The private sector should also be involved in monitoring and publicizing the salt content of foods and meals in national and global markets. The SHAKE package contains guidance and practical case studies to help countries approach these key activities 14 HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT Why it matters In most developed countries, and in a growing number of developing ones, the bulk of the dietary salt (70−80%) comes from processed foods or foods eaten outside the home in restaurants and take-away outlet (14). Promoting the reformulation of food so that it contains less salt is essential to reduce population salt intake and should be one of the first actions considered. In order to achieve this, close collaboration with industry is important. Working closely with the food industry to reformulate food products was key to the success of salt reduction programmes in the United Kingdom (15), and significant progress was made when Argentina (16) and Kuwait (17) worked with industry to reduce the salt added to bread. All Member States of the United Nations, through the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, have recognized the need to reformulate food to produce more options that are consistent with a healthy diet (Figure 2) (18). 15 What needs to be done Promoting the reformulation of food products involves developing a clear set of criteria or targets for salt levels in foods in order to provide a benchmark for the food industry to achieve. These targets can be met through either voluntary or legislative approaches. The key steps are selecting the target foods, engaging with industry, defining the target sodium levels, setting timelines for meeting the target salt levels, and deciding on the mechanisms of implementation. Monitoring changes in salt content across the food supply maintains pressure on the food industry and shows whether voluntary targets are working and whether mandatory targets need to be enforced. The SHAKE package contains guidance and practical case studies to help countries carry out these key steps. The package also contains examples of additional strategies countries could adopt – such as taxes on high- salt foods, and labelling and communication strategies which can encourage the food industry to reformulate. ‘(b) Consider producing and promoting more food products consistent with a healthy diet, including by reformulating products to provide healthier options’ Figure 2 United Nations. Political Declaration on the Prevention and Control of Non-communicable Diseases 16 ADOPT STANDARDS FOR LABELING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD Why it matters Nutrition labelling refers to the disclosure of the main nutrients such as salt, fat, sugar and energy content on the label of a food product. Labelling can also give a rating of whether a food has high or low content of a particular nutrient or set of nutrients, and can warn consumers about foods that are high in an unhealthy nutrient (e.g. sodium). Clear labelling systems that enable consumers to understand the salt content of foods quickly and easily are key to enabling consumers to make properly informed healthy choices when purchasing foods in stores and restaurants. Additionally, standards should be implemented to prevent marketing and labelling that misrepresents salty foods as healthy options because they contain beneficial amounts of other nutrients. Clear and non-misleading labelling has its greatest impact when applied alongside a comprehensive education, communication and marketing campaign to inform and educate consumers. Effective labelling can help consumers understand the salt content of foods quickly and easily 17 What needs to be done A number of labelling strategies can be used to support salt reduction. Different countries have used different strategies depending on the level of existing labelling, cultural norms and consumer preferences. SHAKE has collected sample strategies that countries have successfully used to improve consumer awareness of, and labelling clarity on, salt content. The strategies range from salt warning labels and front-of-pack colour- coded labelling systems (Figure 3) to measures aimed at ensuring that labelling and marketing is accurate and non-misleading. SHAKE provides guidance on how to adapt these labelling strategies from one context to another, and on how to integrate them into existing nutrition labelling systems in use in a country. Figure 3 Example of interpretive front-of-pack “colour code” labelling system 18 KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT Why it matters Consumer awareness is essential to changing consumer behaviour. Generally, the public do not associate the use of salt with high blood pressure and stroke, unlike the common understanding of the link between sugar and diabetes. Consumers are also often not aware of the major sources of sodium in their diet because the high sodium levels in some foods are mostly hidden. Raising awareness of the health impact of high salt consumption and the major sources of sodium in diets will influence consumer behaviour and increase demand for lower-salt food products – a key objective of a sustainable reduction in salt consumption. SHAKE package can support the needs of any country 19 What needs to be done Strategic health education and communication for diet has been identified as a “best buy” because of its demonstrated cost-effectiveness (19). Successful education and communication strategies can lead to changes in social norms related to salt in foods, increased demand for healthier and lower-salt products and, subsequently, improvements in overall health for individuals and communities. The development of communication strategies to influence behaviour should be informed by research, strategically planned to ensure maximum impact, and should include education, social marketing and the use of innovative platforms such as mobile telephones to deliver the messages. Once again, SHAKE is able to help by providing an evidence base of effective education and communication strategies and designs which can be used as models for countries to create their own. The examples vary hugely in size and scope, from a campaign for 95 million people in China to small-scale targeted campaigns run by NGOs. Thus the SHAKE package can support the needs of any country. SHAKE also provides advice and working examples of how governments can collaborate with stakeholders – including the food industry and other partners who can influence the broader food environment – in order to maximize the impact of a campaign. 20 SHAKE offers practical approaches to reducing the levels of salt in food served in schools and workplaces ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING Why it matters Settings are defined as places where people live, work and play. A number of approaches have been successful in reducing the levels of salt in food served in schools, workplaces and other institutional settings. As with children in schools, most adults now spend the vast majority of their time in the workplace. Therefore protecting and promoting health in these settings, including lowering salt intake, is critical (20). What needs to be done SHAKE offers practical approaches to reducing the levels of salt in food served in workplaces and other institutional settings. It provides initial mapping support to help countries identify the key settings where evidence shows that strategies will have the greatest impact – such as schools, workplaces, hospitals and food outlets. It then offers a selection of proven strategies for promoting healthy eating in these settings – such as developing standards for meals served in schools and workplaces – and for behaviour change interventions in community settings. 21 SHAKE also includes cross-sectoral guidance, such as regulatory changes which can be made to reduce salt in public catering, and shows how several countries have created and enforced standards on the maximum levels of salt allowed in foods sold in schools and hospitals. Finally, SHAKE incorporates elements from other related WHO guidance such as recommendations on the marketing of foods and beverages to children. Restricting the marketing of high-salt foods to school children will create a supportive environment for healthy eating from an early age and will produce longer-term positive health behaviours in future generations (21). By bringing all these factors together, the SHAKE package provides a full set of policy tools based on existing practices from around the world. When used in conjunction with strong political commitment, good programme management, a network of partnerships and effective advocacy, SHAKE can help any country create a robust strategy to reduce salt consumption – helping the global population shake its salt habit. 22 ANNEX 1: ELEMENTS OF A SUCCESSFUL SALT REDUCTION PROGRAM While each part of the SHAKE package is important, there are several core elements which bridge them and which will affect success. These cross-cutting areas are political commitment, programme leadership, partnerships, integration with iodine deficiency elimination programmes, and advocacy. Political commitment Political commitment is critical to initiating and sustaining a population-wide salt reduction programme over many years and is also necessary to provide a clear mandate and ensure the availability of adequate resources. Professional groups, nongovernmental organizations (NGOs), academia and consumer groups can lobby government and policy leaders to increase awareness of the importance and feasibility of salt reduction in the public health agenda. 23 Programme leadership and governance One of the most important decisions to make when developing a salt reduction programme is the decision as to who will be responsible for ensuring it is implemented effectively. Salt reduction programmes are most likely to be successful if led from a senior level within government. Ideally the programme should be led by a ministerial-level appointee with a specific interest in the issue and with sufficient support staff and budget to manage the day-to-day operations of the programme. This is especially important for promoting industry compliance when setting targets for the salt content of foods. An effective government leadership team should also be able to garner the support of other stakeholder groups within both civil society and industry. If government leadership is not possible, an NGO or civil society group could lead the work with government support. Advocacy Advocacy denotes activities designed to place salt reduction high on the political and development agendas, to foster political will and to increase financial and other resources for programme development to ensure that implementation is sustainable. Advocacy groups can hold authorities and industry organizations accountable for ensuring that pledges are fulfilled and results achieved. While anyone can 24 advocate for salt reduction, collective action is more likely to be effective than isolated efforts. A broad-based coalition of interrelated and complementary stakeholders can generate dialogue, negotiation and consensus, thus raising awareness and strengthening action for salt reduction. The leadership team should seek to engage the support of stakeholders and the advisory group in whatever capacity possible. Partnerships A multisectoral and multi-stakeholder approach – coupled with strong networking between policy leaders, other government departments, NGOs, consumer groups, the medical community, academia and the food industry – can provide a strong level of support for the salt reduction agenda. An advisory group can support the programme throughout development, implementation and evaluation. The advisory group provides the opportunity to engage with, and use the expertise and interests of, diverse stakeholders that are not directly involved in the programme leadership. It is important that the members of the advisory group have good knowledge of the food industry and good working relationships with a critical mass of key industry representatives and other stakeholders. 25 Integration with iodine deficiency elimination programmes A coordinated approach with those responsible for policies to eliminate iodine deficiency is required to ensure policy coherence and maintain political support for salt reduction. A credible, broad-based advisory group can provide guidance and support for government leaders, bringing together stakeholders from the areas of both salt reduction and iodine deficiency elimination to ensure that a reduction in population salt consumption levels does not adversely affect iodine deficiency elimination programmes and that the promotion of iodized salt does not derail salt reduction efforts. Key areas for integration of the two initiatives include policy development, communication and advocacy, monitoring, and surveillance and research. 26 REFERENCES 1. https://www.washingtonpost.com/news/to-your-health/wp/2014/08/14/salt-intake-is-too- high-in-181-of-187-countries-around-the-world/, accessed 3 June 2016). 2. Berry S. Salt: the single most harmful substance in food? The Sydney Morning Herald. 19 August 2014 (http://www.smh.com.au/lifestyle/diet-and-fitness/salt-the-single-most-harmful- substance-in-food-20140816-104tun.html, accessed 3 June 2016). 3. He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011;378(9789):380−2 (http://www.thelancet.com/pdfs/journals/lancet/ PIIS0140-6736(11)61174-4.pdf, accessed 3 June 2016). 4. Menos sal, más vida. El Litoral. 22 March 2014 (in Spanish) (http://www.ellitoral.com/ index.php/diarios/2014/03/22/nosotros/NOS-05.html, accessed 3 June 2016). 5. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990−2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224−60. 6. 2008−2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: World Health Organization; 2008. 7. Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F. Generalized cost- effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Eff Resour Alloc : C/E. 2009;7:10. 8. Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S, et al. National Diet and Nutrition Survey − assessment of dietary sodium in adults (aged 19 to 64 years) in England, 2011. London: Department of Health 2012. 9. Guideline: sodium intake for adults and children. Geneva: World Health Organization; 2012. 10. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013;3e003733. 27 11. Horton R. Offline: chronic diseases – the social justice issue of our time. Lancet. 2015;386(10011):2378. 12. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370(9604):2044-53. 13. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodrigues-Fernandex R, et al. Salt reduction initiatives around the world – a systematic review of progress towards the global target. PLoS One. 2015;10(7):e0130247. 14. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr. 1991;10(4):383-93. 15. He FJ, Brinsden HC , MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens. 2014;28:345−52. 16. Non-communicable diseases in the Americas: building a healthier future. Washington (DC): Pan American Health Orgnization; 2011. 17. Alhamad N, Almalt E, Alamir N, Subhakaran M. An overview of salt intake reduction efforts in the Gulf Cooperation Council countries. Cardiovasc Diagn Ther. 2015;5(3):172−7. 18. Resolution A/RES/66/2. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York (NY): United Nations; 2012. 19. From burden to “best buys”: reducing the economic impact of NCDs in low- and middle- income countries. Geneva: World Health Organization; 2011. 20. Shain M, Kramer D. Health promotion in the workplace: framing the concept, reviewing the evidence. Occup Environ Med. 2004;61(7):642−8. 21. A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization; 2012. 28
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© World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: bookorders@ who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non- commercial distribution– should be addressed to WHO Press through the WHO website (http://www. who.int/about/licensing/copyright_form/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Graphic design by Studio FFFOG. Printed by the WHO Document Production Services, Geneva, Switzerland. WHO/NMH/PND/16.4
4AN ASSALT ON PUBLIC HEALTH: THE HIDDEN COST OF SALT “Salt intake is too high in 181 of 187 countries around the world” The Washington Post (1) “Salt: the single most harmful substance in food” The Sydney Morning Herald (2) “Salt reduction lowers cardiovascular risk” The Lancet (3) “Menos sal, mas vida” (Less salt, more life) El Litoral (4) These are just a handful of the headlines from the past 18 months when global media have tried again and again to draw attention to the health dangers of eating too much salt. People worldwide consume significantly more salt than they should. Excessive salt consumption is linked to a number of health risks which cause millions of premature deaths annually, such as high blood pressure which accounts for an estimated 9.4 million deaths each year (5). Controlling the threat that salt poses to public health is a challenge facing developed and developing countries alike. The easiest and most cost-effective way of addressing the threat is simple: reduce the amount of salt people eat. Lowering salt consumption is a practical action which can save lives, prevent related diseases and reduce health-care costs for governments and individuals (6-8). Yet the battle against salt has shown that this is easier said than done. The World Health Organization (WHO) recommends a level of salt intake that is less than 5g per day for adults and even less for children (9). Figure 1 shows that salt intake is estimated to be well above the recommended level in almost every country (10). 5The overall global target is a 30% reduction by 2025 in global average population salt consumption. This is the only nutrition-specific target and a core component of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013−2020, which aims to achieve a 25% reduction in premature mortality from avoidable noncommunicable diseases (NCDs) by 2025 (6). Despite strong evidence of the health benefits of salt reduction, policy-makers face many difficulties when translating this evidence into effective public policy. The role of WHO is to bridge this gap, yet a recent article in The Lancet highlighted the organization’s failure to help countries to implement the guidelines it produces (11). In response to this, WHO has reviewed examples of successful salt reduction policies from around the world and has identified a common set of best practices. Successes in countries such as Argentina, Kuwait and the United Kingdom have shown what works, and WHO has collected a range of technical models and interventions from different settings. This evidence base was used to create the SHAKE package. 6“Governments will have the tools to start reducing the amount of salt consumed by their citizens” The SHAKE package is a set of common-sense, evidence-backed policy options and examples which support governments to lower population salt consumption. The options have been chosen because there is evidence that they work as a complete package, are inexpensive as a public health investment, and because WHO has experience in helping countries implement them to the highest standards. Figure 1: Mean sodium intake in persons aged 20 years and over, comparable estimates, 2010 7Mean sodium intake in persons (g/day) <2.75 2.75 - 3.49 3.5 - 4.24 ≥4.25 Data not available Not applicable The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data Source: Powles J et al BMJ Open 2013;3:e003733 World Health Organization. 0 850 1,700 3,400 kilometers 8If the SHAKE package was implemented in every country as a comprehensive package, research indicates that it could save millions of lives per year and dramatically reduce the burden of NCDs on health systems (12). Few countries are fully embracing all of these salt reduction policies and many have taken no action at all to reduce population salt consumption (13). It is hoped that, with these policies and the accompanying resources, governments will have the tools to start reducing the amount of salt consumed by their citizens and to prevent some of the millions of premature deaths caused by cardiovascular diseases. “LOWERING SALT CONSUMPTION IS A PRACTICAL ACTION WHICH CAN SAVE LIVES” 10 THE SHAKE PACKAGE FOR SALT REDUCTION The SHAKE package contains a general framework for the overarching elements needed to create a successful salt reduction strategy: political commitment, programme leadership, partnerships and advocacy (see Annex 1). SHAKE looks at the role of each of these within the main activity areas of a successful national salt reduction strategy, based on the SHAKE acronym: SHAKE THE SALT HABIT 11 SURVEILLANCE MEASURE AND MONITOR SALT USE HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT ADOPT STANDARDS FOR LABELLING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING 12 WHO offers a variety of tools for the monitoring and evaluation of salt reduction SURVEILLANCE MEASURE AND MONITOR SALT USE Why it matters Data from monitoring are necessary to ensure the success of salt reduction interventions. It is important to measure how much salt the population is consuming. This information can be used to show leaders of government and civil society why salt reduction is important and can help them to allocate resources where they will be most effective. It is also essential to identify the dietary sources of salt and to collect information on consumer behaviour so that effective interventions can be designed, implemented and evaluated. What needs to be done There are three key stages in monitoring a salt reduction programme: 1. Measure and monitor population salt consumption patterns. 2. Measure and monitor the sodium content of food. 3. Monitor and evaluate the impact of the salt reduction programme. 13 Within the SHAKE package, WHO offers a variety of tools for monitoring and evaluating salt reduction interventions, including various methods for qualitative and quantitative assessment of a policy, as well as its cost- effectiveness. In order to maximize the quality of monitoring, a range of stakeholders need to be involved. Governments must play a leading role in monitoring and evaluating policies aimed at reducing salt intake at the population level, as well as in allocating funds to support these activities. Nongovernmental organizations, civil society, academia and health-care professionals have significant roles to play in monitoring the implementation of any new policies. The private sector should also be involved in monitoring and publicizing the salt content of foods and meals in national and global markets. The SHAKE package contains guidance and practical case studies to help countries approach these key activities 14 HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT Why it matters In most developed countries, and in a growing number of developing ones, the bulk of the dietary salt (70−80%) comes from processed foods or foods eaten outside the home in restaurants and take-away outlet (14). Promoting the reformulation of food so that it contains less salt is essential to reduce population salt intake and should be one of the first actions considered. In order to achieve this, close collaboration with industry is important. Working closely with the food industry to reformulate food products was key to the success of salt reduction programmes in the United Kingdom (15), and significant progress was made when Argentina (16) and Kuwait (17) worked with industry to reduce the salt added to bread. All Member States of the United Nations, through the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, have recognized the need to reformulate food to produce more options that are consistent with a healthy diet (Figure 2) (18). 15 What needs to be done Promoting the reformulation of food products involves developing a clear set of criteria or targets for salt levels in foods in order to provide a benchmark for the food industry to achieve. These targets can be met through either voluntary or legislative approaches. The key steps are selecting the target foods, engaging with industry, defining the target sodium levels, setting timelines for meeting the target salt levels, and deciding on the mechanisms of implementation. Monitoring changes in salt content across the food supply maintains pressure on the food industry and shows whether voluntary targets are working and whether mandatory targets need to be enforced. The SHAKE package contains guidance and practical case studies to help countries carry out these key steps. The package also contains examples of additional strategies countries could adopt – such as taxes on high- salt foods, and labelling and communication strategies which can encourage the food industry to reformulate. ‘(b) Consider producing and promoting more food products consistent with a healthy diet, including by reformulating products to provide healthier options’ Figure 2 United Nations. Political Declaration on the Prevention and Control of Non-communicable Diseases 16 ADOPT STANDARDS FOR LABELING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD Why it matters Nutrition labelling refers to the disclosure of the main nutrients such as salt, fat, sugar and energy content on the label of a food product. Labelling can also give a rating of whether a food has high or low content of a particular nutrient or set of nutrients, and can warn consumers about foods that are high in an unhealthy nutrient (e.g. sodium). Clear labelling systems that enable consumers to understand the salt content of foods quickly and easily are key to enabling consumers to make properly informed healthy choices when purchasing foods in stores and restaurants. Additionally, standards should be implemented to prevent marketing and labelling that misrepresents salty foods as healthy options because they contain beneficial amounts of other nutrients. Clear and non-misleading labelling has its greatest impact when applied alongside a comprehensive education, communication and marketing campaign to inform and educate consumers. Effective labelling can help consumers understand the salt content of foods quickly and easily 17 What needs to be done A number of labelling strategies can be used to support salt reduction. Different countries have used different strategies depending on the level of existing labelling, cultural norms and consumer preferences. SHAKE has collected sample strategies that countries have successfully used to improve consumer awareness of, and labelling clarity on, salt content. The strategies range from salt warning labels and front-of-pack colour- coded labelling systems (Figure 3) to measures aimed at ensuring that labelling and marketing is accurate and non-misleading. SHAKE provides guidance on how to adapt these labelling strategies from one context to another, and on how to integrate them into existing nutrition labelling systems in use in a country. Figure 3 Example of interpretive front-of-pack “colour code” labelling system 18 KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT Why it matters Consumer awareness is essential to changing consumer behaviour. Generally, the public do not associate the use of salt with high blood pressure and stroke, unlike the common understanding of the link between sugar and diabetes. Consumers are also often not aware of the major sources of sodium in their diet because the high sodium levels in some foods are mostly hidden. Raising awareness of the health impact of high salt consumption and the major sources of sodium in diets will influence consumer behaviour and increase demand for lower-salt food products – a key objective of a sustainable reduction in salt consumption. SHAKE package can support the needs of any country 19 What needs to be done Strategic health education and communication for diet has been identified as a “best buy” because of its demonstrated cost-effectiveness (19). Successful education and communication strategies can lead to changes in social norms related to salt in foods, increased demand for healthier and lower-salt products and, subsequently, improvements in overall health for individuals and communities. The development of communication strategies to influence behaviour should be informed by research, strategically planned to ensure maximum impact, and should include education, social marketing and the use of innovative platforms such as mobile telephones to deliver the messages. Once again, SHAKE is able to help by providing an evidence base of effective education and communication strategies and designs which can be used as models for countries to create their own. The examples vary hugely in size and scope, from a campaign for 95 million people in China to small-scale targeted campaigns run by NGOs. Thus the SHAKE package can support the needs of any country. SHAKE also provides advice and working examples of how governments can collaborate with stakeholders – including the food industry and other partners who can influence the broader food environment – in order to maximize the impact of a campaign. 20 SHAKE offers practical approaches to reducing the levels of salt in food served in schools and workplaces ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING Why it matters Settings are defined as places where people live, work and play. A number of approaches have been successful in reducing the levels of salt in food served in schools, workplaces and other institutional settings. As with children in schools, most adults now spend the vast majority of their time in the workplace. Therefore protecting and promoting health in these settings, including lowering salt intake, is critical (20). What needs to be done SHAKE offers practical approaches to reducing the levels of salt in food served in workplaces and other institutional settings. It provides initial mapping support to help countries identify the key settings where evidence shows that strategies will have the greatest impact – such as schools, workplaces, hospitals and food outlets. It then offers a selection of proven strategies for promoting healthy eating in these settings – such as developing standards for meals served in schools and workplaces – and for behaviour change interventions in community settings. 21 SHAKE also includes cross-sectoral guidance, such as regulatory changes which can be made to reduce salt in public catering, and shows how several countries have created and enforced standards on the maximum levels of salt allowed in foods sold in schools and hospitals. Finally, SHAKE incorporates elements from other related WHO guidance such as recommendations on the marketing of foods and beverages to children. Restricting the marketing of high-salt foods to school children will create a supportive environment for healthy eating from an early age and will produce longer-term positive health behaviours in future generations (21). By bringing all these factors together, the SHAKE package provides a full set of policy tools based on existing practices from around the world. When used in conjunction with strong political commitment, good programme management, a network of partnerships and effective advocacy, SHAKE can help any country create a robust strategy to reduce salt consumption – helping the global population shake its salt habit. 22 ANNEX 1: ELEMENTS OF A SUCCESSFUL SALT REDUCTION PROGRAM While each part of the SHAKE package is important, there are several core elements which bridge them and which will affect success. These cross-cutting areas are political commitment, programme leadership, partnerships, integration with iodine deficiency elimination programmes, and advocacy. Political commitment Political commitment is critical to initiating and sustaining a population-wide salt reduction programme over many years and is also necessary to provide a clear mandate and ensure the availability of adequate resources. Professional groups, nongovernmental organizations (NGOs), academia and consumer groups can lobby government and policy leaders to increase awareness of the importance and feasibility of salt reduction in the public health agenda. 23 Programme leadership and governance One of the most important decisions to make when developing a salt reduction programme is the decision as to who will be responsible for ensuring it is implemented effectively. Salt reduction programmes are most likely to be successful if led from a senior level within government. Ideally the programme should be led by a ministerial-level appointee with a specific interest in the issue and with sufficient support staff and budget to manage the day-to-day operations of the programme. This is especially important for promoting industry compliance when setting targets for the salt content of foods. An effective government leadership team should also be able to garner the support of other stakeholder groups within both civil society and industry. If government leadership is not possible, an NGO or civil society group could lead the work with government support. Advocacy Advocacy denotes activities designed to place salt reduction high on the political and development agendas, to foster political will and to increase financial and other resources for programme development to ensure that implementation is sustainable. Advocacy groups can hold authorities and industry organizations accountable for ensuring that pledges are fulfilled and results achieved. While anyone can 24 advocate for salt reduction, collective action is more likely to be effective than isolated efforts. A broad-based coalition of interrelated and complementary stakeholders can generate dialogue, negotiation and consensus, thus raising awareness and strengthening action for salt reduction. The leadership team should seek to engage the support of stakeholders and the advisory group in whatever capacity possible. Partnerships A multisectoral and multi-stakeholder approach – coupled with strong networking between policy leaders, other government departments, NGOs, consumer groups, the medical community, academia and the food industry – can provide a strong level of support for the salt reduction agenda. An advisory group can support the programme throughout development, implementation and evaluation. The advisory group provides the opportunity to engage with, and use the expertise and interests of, diverse stakeholders that are not directly involved in the programme leadership. It is important that the members of the advisory group have good knowledge of the food industry and good working relationships with a critical mass of key industry representatives and other stakeholders. 25 Integration with iodine deficiency elimination programmes A coordinated approach with those responsible for policies to eliminate iodine deficiency is required to ensure policy coherence and maintain political support for salt reduction. A credible, broad-based advisory group can provide guidance and support for government leaders, bringing together stakeholders from the areas of both salt reduction and iodine deficiency elimination to ensure that a reduction in population salt consumption levels does not adversely affect iodine deficiency elimination programmes and that the promotion of iodized salt does not derail salt reduction efforts. Key areas for integration of the two initiatives include policy development, communication and advocacy, monitoring, and surveillance and research. 26 REFERENCES 1. https://www.washingtonpost.com/news/to-your-health/wp/2014/08/14/salt-intake-is-too- high-in-181-of-187-countries-around-the-world/, accessed 3 June 2016). 2. Berry S. Salt: the single most harmful substance in food? The Sydney Morning Herald. 19 August 2014 (http://www.smh.com.au/lifestyle/diet-and-fitness/salt-the-single-most-harmful- substance-in-food-20140816-104tun.html, accessed 3 June 2016). 3. He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011;378(9789):380−2 (http://www.thelancet.com/pdfs/journals/lancet/ PIIS0140-6736(11)61174-4.pdf, accessed 3 June 2016). 4. Menos sal, más vida. El Litoral. 22 March 2014 (in Spanish) (http://www.ellitoral.com/ index.php/diarios/2014/03/22/nosotros/NOS-05.html, accessed 3 June 2016). 5. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990−2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224−60. 6. 2008−2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: World Health Organization; 2008. 7. Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F. Generalized cost- effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Eff Resour Alloc : C/E. 2009;7:10. 8. Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S, et al. National Diet and Nutrition Survey − assessment of dietary sodium in adults (aged 19 to 64 years) in England, 2011. London: Department of Health 2012. 9. Guideline: sodium intake for adults and children. Geneva: World Health Organization; 2012. 10. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013;3e003733. 27 11. Horton R. Offline: chronic diseases – the social justice issue of our time. Lancet. 2015;386(10011):2378. 12. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370(9604):2044-53. 13. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodrigues-Fernandex R, et al. Salt reduction initiatives around the world – a systematic review of progress towards the global target. PLoS One. 2015;10(7):e0130247. 14. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr. 1991;10(4):383-93. 15. He FJ, Brinsden HC , MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens. 2014;28:345−52. 16. Non-communicable diseases in the Americas: building a healthier future. Washington (DC): Pan American Health Orgnization; 2011. 17. Alhamad N, Almalt E, Alamir N, Subhakaran M. An overview of salt intake reduction efforts in the Gulf Cooperation Council countries. Cardiovasc Diagn Ther. 2015;5(3):172−7. 18. Resolution A/RES/66/2. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York (NY): United Nations; 2012. 19. From burden to “best buys”: reducing the economic impact of NCDs in low- and middle- income countries. Geneva: World Health Organization; 2011. 20. Shain M, Kramer D. Health promotion in the workplace: framing the concept, reviewing the evidence. Occup Environ Med. 2004;61(7):642−8. 21. A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization; 2012. 28
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4AN ASSALT ON PUBLIC HEALTH: THE HIDDEN COST OF SALT “Salt intake is too high in 181 of 187 countries around the world” The Washington Post (1) “Salt: the single most harmful substance in food” The Sydney Morning Herald (2) “Salt reduction lowers cardiovascular risk” The Lancet (3) “Menos sal, mas vida” (Less salt, more life) El Litoral (4) These are just a handful of the headlines from the past 18 months when global media have tried again and again to draw attention to the health dangers of eating too much salt. People worldwide consume significantly more salt than they should. Excessive salt consumption is linked to a number of health risks which cause millions of premature deaths annually, such as high blood pressure which accounts for an estimated 9.4 million deaths each year (5). Controlling the threat that salt poses to public health is a challenge facing developed and developing countries alike. The easiest and most cost-effective way of addressing the threat is simple: reduce the amount of salt people eat. Lowering salt consumption is a practical action which can save lives, prevent related diseases and reduce health-care costs for governments and individuals (6-8). Yet the battle against salt has shown that this is easier said than done. The World Health Organization (WHO) recommends a level of salt intake that is less than 5g per day for adults and even less for children (9). Figure 1 shows that salt intake is estimated to be well above the recommended level in almost every country (10). 5The overall global target is a 30% reduction by 2025 in global average population salt consumption. This is the only nutrition-specific target and a core component of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013−2020, which aims to achieve a 25% reduction in premature mortality from avoidable noncommunicable diseases (NCDs) by 2025 (6). Despite strong evidence of the health benefits of salt reduction, policy-makers face many difficulties when translating this evidence into effective public policy. The role of WHO is to bridge this gap, yet a recent article in The Lancet highlighted the organization’s failure to help countries to implement the guidelines it produces (11). In response to this, WHO has reviewed examples of successful salt reduction policies from around the world and has identified a common set of best practices. Successes in countries such as Argentina, Kuwait and the United Kingdom have shown what works, and WHO has collected a range of technical models and interventions from different settings. This evidence base was used to create the SHAKE package. 6“Governments will have the tools to start reducing the amount of salt consumed by their citizens” The SHAKE package is a set of common-sense, evidence-backed policy options and examples which support governments to lower population salt consumption. The options have been chosen because there is evidence that they work as a complete package, are inexpensive as a public health investment, and because WHO has experience in helping countries implement them to the highest standards. Figure 1: Mean sodium intake in persons aged 20 years and over, comparable estimates, 2010 7Mean sodium intake in persons (g/day) <2.75 2.75 - 3.49 3.5 - 4.24 ≥4.25 Data not available Not applicable The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Data Source: Powles J et al BMJ Open 2013;3:e003733 World Health Organization. 0 850 1,700 3,400 kilometers 8If the SHAKE package was implemented in every country as a comprehensive package, research indicates that it could save millions of lives per year and dramatically reduce the burden of NCDs on health systems (12). Few countries are fully embracing all of these salt reduction policies and many have taken no action at all to reduce population salt consumption (13). It is hoped that, with these policies and the accompanying resources, governments will have the tools to start reducing the amount of salt consumed by their citizens and to prevent some of the millions of premature deaths caused by cardiovascular diseases. “LOWERING SALT CONSUMPTION IS A PRACTICAL ACTION WHICH CAN SAVE LIVES” 10 THE SHAKE PACKAGE FOR SALT REDUCTION The SHAKE package contains a general framework for the overarching elements needed to create a successful salt reduction strategy: political commitment, programme leadership, partnerships and advocacy (see Annex 1). SHAKE looks at the role of each of these within the main activity areas of a successful national salt reduction strategy, based on the SHAKE acronym: SHAKE THE SALT HABIT 11 SURVEILLANCE MEASURE AND MONITOR SALT USE HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT ADOPT STANDARDS FOR LABELLING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING 12 WHO offers a variety of tools for the monitoring and evaluation of salt reduction SURVEILLANCE MEASURE AND MONITOR SALT USE Why it matters Data from monitoring are necessary to ensure the success of salt reduction interventions. It is important to measure how much salt the population is consuming. This information can be used to show leaders of government and civil society why salt reduction is important and can help them to allocate resources where they will be most effective. It is also essential to identify the dietary sources of salt and to collect information on consumer behaviour so that effective interventions can be designed, implemented and evaluated. What needs to be done There are three key stages in monitoring a salt reduction programme: 1. Measure and monitor population salt consumption patterns. 2. Measure and monitor the sodium content of food. 3. Monitor and evaluate the impact of the salt reduction programme. 13 Within the SHAKE package, WHO offers a variety of tools for monitoring and evaluating salt reduction interventions, including various methods for qualitative and quantitative assessment of a policy, as well as its cost- effectiveness. In order to maximize the quality of monitoring, a range of stakeholders need to be involved. Governments must play a leading role in monitoring and evaluating policies aimed at reducing salt intake at the population level, as well as in allocating funds to support these activities. Nongovernmental organizations, civil society, academia and health-care professionals have significant roles to play in monitoring the implementation of any new policies. The private sector should also be involved in monitoring and publicizing the salt content of foods and meals in national and global markets. The SHAKE package contains guidance and practical case studies to help countries approach these key activities 14 HARNESS INDUSTRY PROMOTE REFORMULATION OF FOODS AND MEALS TO CONTAIN LESS SALT Why it matters In most developed countries, and in a growing number of developing ones, the bulk of the dietary salt (70−80%) comes from processed foods or foods eaten outside the home in restaurants and take-away outlet (14). Promoting the reformulation of food so that it contains less salt is essential to reduce population salt intake and should be one of the first actions considered. In order to achieve this, close collaboration with industry is important. Working closely with the food industry to reformulate food products was key to the success of salt reduction programmes in the United Kingdom (15), and significant progress was made when Argentina (16) and Kuwait (17) worked with industry to reduce the salt added to bread. All Member States of the United Nations, through the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, have recognized the need to reformulate food to produce more options that are consistent with a healthy diet (Figure 2) (18). 15 What needs to be done Promoting the reformulation of food products involves developing a clear set of criteria or targets for salt levels in foods in order to provide a benchmark for the food industry to achieve. These targets can be met through either voluntary or legislative approaches. The key steps are selecting the target foods, engaging with industry, defining the target sodium levels, setting timelines for meeting the target salt levels, and deciding on the mechanisms of implementation. Monitoring changes in salt content across the food supply maintains pressure on the food industry and shows whether voluntary targets are working and whether mandatory targets need to be enforced. The SHAKE package contains guidance and practical case studies to help countries carry out these key steps. The package also contains examples of additional strategies countries could adopt – such as taxes on high- salt foods, and labelling and communication strategies which can encourage the food industry to reformulate. ‘(b) Consider producing and promoting more food products consistent with a healthy diet, including by reformulating products to provide healthier options’ Figure 2 United Nations. Political Declaration on the Prevention and Control of Non-communicable Diseases 16 ADOPT STANDARDS FOR LABELING AND MARKETING IMPLEMENT STANDARDS FOR EFFECTIVE AND ACCURATE LABELLING AND MARKETING OF FOOD Why it matters Nutrition labelling refers to the disclosure of the main nutrients such as salt, fat, sugar and energy content on the label of a food product. Labelling can also give a rating of whether a food has high or low content of a particular nutrient or set of nutrients, and can warn consumers about foods that are high in an unhealthy nutrient (e.g. sodium). Clear labelling systems that enable consumers to understand the salt content of foods quickly and easily are key to enabling consumers to make properly informed healthy choices when purchasing foods in stores and restaurants. Additionally, standards should be implemented to prevent marketing and labelling that misrepresents salty foods as healthy options because they contain beneficial amounts of other nutrients. Clear and non-misleading labelling has its greatest impact when applied alongside a comprehensive education, communication and marketing campaign to inform and educate consumers. Effective labelling can help consumers understand the salt content of foods quickly and easily 17 What needs to be done A number of labelling strategies can be used to support salt reduction. Different countries have used different strategies depending on the level of existing labelling, cultural norms and consumer preferences. SHAKE has collected sample strategies that countries have successfully used to improve consumer awareness of, and labelling clarity on, salt content. The strategies range from salt warning labels and front-of-pack colour- coded labelling systems (Figure 3) to measures aimed at ensuring that labelling and marketing is accurate and non-misleading. SHAKE provides guidance on how to adapt these labelling strategies from one context to another, and on how to integrate them into existing nutrition labelling systems in use in a country. Figure 3 Example of interpretive front-of-pack “colour code” labelling system 18 KNOWLEDGE EDUCATE AND COMMUNICATE TO EMPOWER INDIVIDUALS TO EAT LESS SALT Why it matters Consumer awareness is essential to changing consumer behaviour. Generally, the public do not associate the use of salt with high blood pressure and stroke, unlike the common understanding of the link between sugar and diabetes. Consumers are also often not aware of the major sources of sodium in their diet because the high sodium levels in some foods are mostly hidden. Raising awareness of the health impact of high salt consumption and the major sources of sodium in diets will influence consumer behaviour and increase demand for lower-salt food products – a key objective of a sustainable reduction in salt consumption. SHAKE package can support the needs of any country 19 What needs to be done Strategic health education and communication for diet has been identified as a “best buy” because of its demonstrated cost-effectiveness (19). Successful education and communication strategies can lead to changes in social norms related to salt in foods, increased demand for healthier and lower-salt products and, subsequently, improvements in overall health for individuals and communities. The development of communication strategies to influence behaviour should be informed by research, strategically planned to ensure maximum impact, and should include education, social marketing and the use of innovative platforms such as mobile telephones to deliver the messages. Once again, SHAKE is able to help by providing an evidence base of effective education and communication strategies and designs which can be used as models for countries to create their own. The examples vary hugely in size and scope, from a campaign for 95 million people in China to small-scale targeted campaigns run by NGOs. Thus the SHAKE package can support the needs of any country. SHAKE also provides advice and working examples of how governments can collaborate with stakeholders – including the food industry and other partners who can influence the broader food environment – in order to maximize the impact of a campaign. 20 SHAKE offers practical approaches to reducing the levels of salt in food served in schools and workplaces ENVIRONMENT SUPPORT SETTINGS TO PROMOTE HEALTHY EATING Why it matters Settings are defined as places where people live, work and play. A number of approaches have been successful in reducing the levels of salt in food served in schools, workplaces and other institutional settings. As with children in schools, most adults now spend the vast majority of their time in the workplace. Therefore protecting and promoting health in these settings, including lowering salt intake, is critical (20). What needs to be done SHAKE offers practical approaches to reducing the levels of salt in food served in workplaces and other institutional settings. It provides initial mapping support to help countries identify the key settings where evidence shows that strategies will have the greatest impact – such as schools, workplaces, hospitals and food outlets. It then offers a selection of proven strategies for promoting healthy eating in these settings – such as developing standards for meals served in schools and workplaces – and for behaviour change interventions in community settings. 21 SHAKE also includes cross-sectoral guidance, such as regulatory changes which can be made to reduce salt in public catering, and shows how several countries have created and enforced standards on the maximum levels of salt allowed in foods sold in schools and hospitals. Finally, SHAKE incorporates elements from other related WHO guidance such as recommendations on the marketing of foods and beverages to children. Restricting the marketing of high-salt foods to school children will create a supportive environment for healthy eating from an early age and will produce longer-term positive health behaviours in future generations (21). By bringing all these factors together, the SHAKE package provides a full set of policy tools based on existing practices from around the world. When used in conjunction with strong political commitment, good programme management, a network of partnerships and effective advocacy, SHAKE can help any country create a robust strategy to reduce salt consumption – helping the global population shake its salt habit. 22 ANNEX 1: ELEMENTS OF A SUCCESSFUL SALT REDUCTION PROGRAM While each part of the SHAKE package is important, there are several core elements which bridge them and which will affect success. These cross-cutting areas are political commitment, programme leadership, partnerships, integration with iodine deficiency elimination programmes, and advocacy. Political commitment Political commitment is critical to initiating and sustaining a population-wide salt reduction programme over many years and is also necessary to provide a clear mandate and ensure the availability of adequate resources. Professional groups, nongovernmental organizations (NGOs), academia and consumer groups can lobby government and policy leaders to increase awareness of the importance and feasibility of salt reduction in the public health agenda. 23 Programme leadership and governance One of the most important decisions to make when developing a salt reduction programme is the decision as to who will be responsible for ensuring it is implemented effectively. Salt reduction programmes are most likely to be successful if led from a senior level within government. Ideally the programme should be led by a ministerial-level appointee with a specific interest in the issue and with sufficient support staff and budget to manage the day-to-day operations of the programme. This is especially important for promoting industry compliance when setting targets for the salt content of foods. An effective government leadership team should also be able to garner the support of other stakeholder groups within both civil society and industry. If government leadership is not possible, an NGO or civil society group could lead the work with government support. Advocacy Advocacy denotes activities designed to place salt reduction high on the political and development agendas, to foster political will and to increase financial and other resources for programme development to ensure that implementation is sustainable. Advocacy groups can hold authorities and industry organizations accountable for ensuring that pledges are fulfilled and results achieved. While anyone can 24 advocate for salt reduction, collective action is more likely to be effective than isolated efforts. A broad-based coalition of interrelated and complementary stakeholders can generate dialogue, negotiation and consensus, thus raising awareness and strengthening action for salt reduction. The leadership team should seek to engage the support of stakeholders and the advisory group in whatever capacity possible. Partnerships A multisectoral and multi-stakeholder approach – coupled with strong networking between policy leaders, other government departments, NGOs, consumer groups, the medical community, academia and the food industry – can provide a strong level of support for the salt reduction agenda. An advisory group can support the programme throughout development, implementation and evaluation. The advisory group provides the opportunity to engage with, and use the expertise and interests of, diverse stakeholders that are not directly involved in the programme leadership. It is important that the members of the advisory group have good knowledge of the food industry and good working relationships with a critical mass of key industry representatives and other stakeholders. 25 Integration with iodine deficiency elimination programmes A coordinated approach with those responsible for policies to eliminate iodine deficiency is required to ensure policy coherence and maintain political support for salt reduction. A credible, broad-based advisory group can provide guidance and support for government leaders, bringing together stakeholders from the areas of both salt reduction and iodine deficiency elimination to ensure that a reduction in population salt consumption levels does not adversely affect iodine deficiency elimination programmes and that the promotion of iodized salt does not derail salt reduction efforts. Key areas for integration of the two initiatives include policy development, communication and advocacy, monitoring, and surveillance and research. 26 REFERENCES 1. https://www.washingtonpost.com/news/to-your-health/wp/2014/08/14/salt-intake-is-too- high-in-181-of-187-countries-around-the-world/, accessed 3 June 2016). 2. Berry S. Salt: the single most harmful substance in food? The Sydney Morning Herald. 19 August 2014 (http://www.smh.com.au/lifestyle/diet-and-fitness/salt-the-single-most-harmful- substance-in-food-20140816-104tun.html, accessed 3 June 2016). 3. He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011;378(9789):380−2 (http://www.thelancet.com/pdfs/journals/lancet/ PIIS0140-6736(11)61174-4.pdf, accessed 3 June 2016). 4. Menos sal, más vida. El Litoral. 22 March 2014 (in Spanish) (http://www.ellitoral.com/ index.php/diarios/2014/03/22/nosotros/NOS-05.html, accessed 3 June 2016). 5. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990−2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224−60. 6. 2008−2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: World Health Organization; 2008. 7. Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F. Generalized cost- effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Eff Resour Alloc : C/E. 2009;7:10. 8. Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S, et al. National Diet and Nutrition Survey − assessment of dietary sodium in adults (aged 19 to 64 years) in England, 2011. London: Department of Health 2012. 9. Guideline: sodium intake for adults and children. Geneva: World Health Organization; 2012. 10. Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open. 2013;3e003733. 27 11. Horton R. Offline: chronic diseases – the social justice issue of our time. Lancet. 2015;386(10011):2378. 12. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370(9604):2044-53. 13. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodrigues-Fernandex R, et al. Salt reduction initiatives around the world – a systematic review of progress towards the global target. PLoS One. 2015;10(7):e0130247. 14. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr. 1991;10(4):383-93. 15. He FJ, Brinsden HC , MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens. 2014;28:345−52. 16. Non-communicable diseases in the Americas: building a healthier future. Washington (DC): Pan American Health Orgnization; 2011. 17. Alhamad N, Almalt E, Alamir N, Subhakaran M. An overview of salt intake reduction efforts in the Gulf Cooperation Council countries. Cardiovasc Diagn Ther. 2015;5(3):172−7. 18. Resolution A/RES/66/2. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. New York (NY): United Nations; 2012. 19. From burden to “best buys”: reducing the economic impact of NCDs in low- and middle- income countries. Geneva: World Health Organization; 2011. 20. Shain M, Kramer D. Health promotion in the workplace: framing the concept, reviewing the evidence. Occup Environ Med. 2004;61(7):642−8. 21. A framework for implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization; 2012. 28
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改变吃盐的习惯 世界卫生组织，2016年 版权所有。世界卫生组织出版物可从世卫组织网站（www.who.int）获得，或者自WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland（电话：+41 22 791 3264；传真：+41 22 791 4857；电子邮件：bookorders@who.int）购买。 要获得复制许可或翻译世界卫生组织出版物的许可——无论是为了出售或非商业性分发，应通过 世卫组织网站（http://www.who.int/about/licensing/copyright_form/index.html）向世界卫生组织 出版处提出申请。 本出版物采用的名称和陈述的材料并不代表世界卫生组织对任何国家、领地、城市或地区或其当 局的合法地位，或关于边界或分界线的规定有任何意见。地图上的虚线表示可能尚未完全达成一致的 大致边界线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世界卫生组织所认可或推荐，或比 其它未提及的同类公司或产品更好。除差错和疏忽外，凡专利产品名称均冠以大写字母，以示区别。 世界卫生组织已采取一切合理的预防措施来核实本出版物中包含的信息。但是，已出版材料的分 发无任何明确或含蓄的保证。解释和使用材料的责任取决于读者。世界卫生组织对于因使用这些材料 造成的损失不承担责任。 瑞士日内瓦世卫组织文件编印服务处印刷 Graphic design by Studio FFFOG. Printed in Switzerland. WHO/NMH/PND/16.4 改变吃盐的习惯 4改变吃盐的习惯 对公共卫生的冲击： 盐的隐蔽成本 在过去18个月，全球媒体一再尝试 提请注意吃太多盐的健康危害。以上只 是其中少数头条新闻。全世界人们摄入 的盐比他们的需要多得多。过量摄入盐 与每年导致数百万人过早死亡的若干健 康风险相关，例如高血压每年造成约940 万人死亡5。控制盐对公共卫生造成的 威胁是发达国家和发展中国家同样面临 的挑战。解决威胁的最简单和最具成本 效益的方法很简单：减少人们的盐摄入 量。减少盐摄入量是一项切实可行的行 动，可以挽救生命，预防相关疾病，降 低政府和个人的卫生保健费用6,7,8。 然而，针对盐的战斗表明，说起来 容易，做起来难。世界卫生组织建议成 年人每日盐摄入量应少于5克，而儿童还 要少9。图1显示，几乎所有国家中的盐摄 入量估计远高于建议的水平10。全球总目 标是到2025年使全球人口的平均盐消费 量减少30%。这是《2013-2020年预防 和控制非传染性疾病全球行动计划》中 唯一针对营养的具体目标，也是其中的 “世界各地187个 国家中有181个 国家的盐摄入量 过高” （华盛顿邮报）1 盐：食物中单一最 有害的物质？ （悉尼先驱晨报）2 减盐可降低 心血管风险 （柳叶刀）3 “Menos sal, mas vida（少盐益寿）” （El Litoral）4 5一个核心组成部分。该行动计划旨在到 2025年使可避免的非传染性疾病过早死 亡率降低25%6。尽管存在有力的证据表 明减盐的健康效益，但决策者在把这些 证据转化为有效的公共政策时面临着许 多困难。世卫组织的作用是弥合这一差 距，但《柳叶刀》最近的一篇文章突出 地显示本组织未能帮助各国执行其制定 的准则11。 针对这一点，世卫组织回顾了世界各 地成功减盐政策的实例，并确定了一套 共同的最佳做法。阿根廷、科威特和英 国等国家的成功表明哪些措施有效，而 且世卫组织收集了来自不同环境的一系 列技术模型和干预措施。此证据基础被 用于创建SHAKE一揽子计划。 6 SHAKE一揽子计划是一套常识性、 由证据支持的政策方案和示例，支持政 府减少人口的盐消费量。选择这些方案 是因为有证据表明它们作为完整的一揽 子计划行之有效，作为公共卫生投资费 用不高，而且世卫组织有经验帮助国家 开展最高标准的实施工作。 图1：20岁以上人口平均钠摄入量，2010年可比估值 政府将有工具以 开始减少本国公 民的盐摄入量 7人口平均钠摄入量（克/日） <2.75 2.75 - 3.49 3.5 - 4.24 ≥4.25 无数据 不适用 本出版物采用的名称和陈述的材料并不代表世界卫生组织对任何国家、领 地、城巿或地区或其当局的合法地位，或关于边界或分界线的规定有任何意见。 地图上的虛线表示可能尚未完全达成一致的大致边界线。数据来源：Powels J 等，BMJ Open 2013:e003733。世界卫生组织 0 850 1,700 3,400 公里 8 如果SHAKE一揽子计划作为一种综 合性一揽子计划在每个国家实施，研究 表明每年可以挽救几百万人的生命，并 大大减轻非传染性疾病对卫生系统的负 担12。很少有国家完全接受所有这些减盐 政策，许多国家根本没有采取任何行动 来减少人口的盐消费量13。通过这些政 策和相关资源，希望各国政府将拥有工 具，可以开始减少公民的盐摄入量，并 能对心血管疾病引起的数百万例过早死 亡起到一定的预防作用。 “减少盐摄入量是 挽救生命的实际行动” 10 SHAKE一揽子减盐 计划 SHAKE一揽子计划包含一个总体框 架，用于创建成功的减盐战略所需的总 体要素：政治承诺、规划领导力、伙伴 关系和宣传（见附件1）。根据SHAKE首 字母的缩略，SHAKE分别考虑到这些要 素在国家成功减盐战略各主要活动领域 中的作用： “改变吃盐的习惯” 11 SURVEILLANCE （监测）： 衡量和监测盐的使用情况 HARNESS INDUSTRY （管控行业部门）： 促进改变食品和膳食配方，减少盐分含量 ADOPT STANDARDS FOR LABELLING AND MARKETING （采用标签和营销标准）： 执行有效和准确的食品标签和营销标准 KNOWLEDGE （知识）： 开展教育和宣传，促使人们食用较少的盐 ENVIRONMENT （环境）： 支持促进健康饮食的环境 12 世卫组织提供了 多种用于监测和 评价减盐的工具 监测 衡量和监测盐的使用情况 为什么事关重大 监测数据是确保减盐干预措施取得成 功的必要条件。衡量人口摄入多少盐是 很重要的。这种信息可以用来向政府和 民间社会领导人展示为什么减盐是重要 的，并且可以帮助他们配置经费用于可 产生最大效益的地方。确定盐的膳食来 源并收集有关消费者习惯的信息也是至 关重要的，由此可以设计、实施和评价 有效的干预措施。 需要做什么 对减盐规划进行的监测包括三个关键 阶段： 1. 衡量和监测人口的盐消费 模式。 • 2. 衡量和监测食品中钠的含 量。 • 3. 监测和评价减盐规划的 影响。 13 在SHAKE一揽子计划中，世卫组织 提供了监测和评价减盐干预措施的各种 工具，包括对政策及其成本效益进行定 性和定量评估的各种方法。 为了最大限度地提高监测质量，需要 涉及一系列利益攸关方。各国政府必须 发挥主导作用，监测和评价旨在减少人 口盐摄入量的政策，并配置经费支持这 些活动。非政府组织、民间社会、学术 界和卫生保健专业人员在监测任何新政 策的实施过程中都可发挥重要作用。私 立部门也应参与监测和公开国家和全球 市场食品和膳食的盐分含量。 SHAKE一揽子计 划包含指导和实 用案例研究，以 帮助各国处理 这些活动 14 管控行业部门 促进改变食品和膳食配方，减 少盐分含量 为什么事关重大 在大多数发达国家和越来越多的发展 中国家，大部分膳食盐（70-80%）来 自加工食品或餐馆和外卖店等在家以外 的地方吃的食物14。促进改变食品配方以 减少盐分含量，对于减少人口的盐摄入 量至关重要，应是首先考虑采取的行动 之一。为了实现这一点，与行业部门的 密切合作是很重要的。与食品行业密切 合作以改变食品配方是英国减盐规划取 得成功的关键15，阿根廷16和科威特17在与 行业部门合作减少面包中盐添加方面也 取得了重大进展。通过《联合国大会预 防和控制非传染性疾病问题高级别会议 政治宣言》，联合国所有成员国都认识 到需要改变食品配方，以便产生更多符 合健康饮食的方案（图2）18。 15 需要做什么 促进改变食品配方涉及针对食品中 盐的含量制定一套明确标准或目标，为 食品行业提供基准。这些目标可以通过 自愿或立法程序来实现。关键步骤是选 择目标食品，与行业部门合作，规定钠 含量目标，制定达到盐含量目标的时间 安排，并确定实施机制。监测食品供应 中盐含量的变化，会对食品行业造成压 力，并可以表明自愿目标是否有效，以 及是否需要执行强制性的目标。SHAKE 一揽子计划包含指导和实用案例研究， 以帮助各国执行这些关键步骤。一揽子 计划还包括各国可采取的其它策略的例 子，例如对高盐食品征税，以及可以鼓 励食品行业改变食品配方的标签和宣传 策略。 ‘(b) 考虑生产和促销更多符合健康饮食要求 的食品，包括为此而改变产品配方以提供更健康 的选择’ 图2： 联合国预防和 控制非传染性疾病的 政治宣言 16 采用标签和营销标准 执行有效和准确的食品标签和 营销标准 为什么事关重大 营养标签是指在食品标签上披露主 要营养成分，如盐、脂肪、糖和能量 的含量。标签还可以对食品中特定营 养素或一组营养素含量的高低进行评 级，并且可以向消费者警示不健康营养 物质（例如钠）含量较高的食品。清晰 的标签系统使消费者能够迅速和方便地 了解食品的盐分含量，是消费者在商店 和餐馆购买食品时能够做出适当知情 的健康选择的关键。此外，应该执行 标准，防止营销活动和所贴的标签因 为咸的食品中含有其它有益的营养成 分而错误地将其作为健康的选择。当伴 随为消费者提供信息和教育的综合教 育、宣传和营销活动应用时，明确而不 具误导性的标签具有最大的影响力。 有效的标签可以 帮助消费者迅速 和方便地了解食 品的盐分含量 17 需要做什么 若干标签策略可用于支持减盐。不 同的国家根据现有标签的水平、文化 规范和消费者偏好，采用了不同的策 略。SHAKE收集了各国为提高消费者对 盐含量的认识和标签描述盐含量的明确 程度而成功使用的样本策略。策略范围 从盐分警示标签和包装正面彩色标签系 统（图3）到旨在确保标签和营销准确无 误的措施。SHAKE提供了指导，说明如 何根据具体环境调整这些标签策略，以 及如何将策略纳入国家现行的营养标签 系统中。 图3： 包装正面彩色 解释性标签系统示例 每30克麦片： 份 能量 460千焦 110千卡 占成人参考摄入量的百分比 每100克的典型数值：能量为1530千焦/360千卡 低 脂肪 低 饱和脂肪 高 糖 中等 盐 18 知识 开展教育和宣传，促使人们食用 较少的盐 为什么事关重大 消费者意识对改变消费习惯至关重 要。一般来说，公众不会将吃盐与高血 压和中风联系起来，这与对糖和糖尿病 之间联系的一般理解不同。消费者也常 常不了解自己饮食中钠的主要来源，因 为一些食物中的高钠含量大都是隐蔽 的。提高对高盐消费的健康影响以及饮 食中钠主要来源的意识，将影响消费习 惯并增加对低盐食品的需求，这也是持 续减少盐消费的一个重要目标。 SHAKE一揽 子计划可以 支持任何国 家的需求 19 需要做什么 由于已表明具有成本效益，战略性 的饮食问题健康教育和宣传已被确定为 一种“最合算的措施”19。成功的教育和 宣传策略可以导致与食品中的盐相关的 社会规范发生变化，增加对更健康和低 盐产品的需求，从而改善个人和社区的 整体健康状况。制定宣传策略以影响行 为，应该得到研究结果的充实，从战略 角度进行规划以确保最大程度的影响， 并应包括教育、社会营销和使用移动电 话等创新平台来传递信息。 同样，通过为有效的教育和宣传策 略及设计提供证据基础，SHAKE能够 给予帮助，而这些策略和设计可以作为 模型，使各国能够创建本国的策略和设 计。这方面的例子从中国9500万人的运 动到非政府组织开展的小规模有针对性 的运动，在规模和范围上差别很大。因 此，SHAKE一揽子计划可以支持任何国 家的需求。SHAKE还提供意见和工作实 例，说明政府如何与利益攸关方（包括 食品行业及其它可能影响更广泛食品环 境的伙伴）合作，以便最大限度地发挥 宣传运动的影响。 20 SHAKE提供了实 用的方法，以便 在学校和工作场 所提供的食物中 减少盐分含量 环境 支持促进健康饮食的环境 为什么事关重大 环境被定义为人们生活、工作和娱乐 的场所。若干方法已经成功地在学校、 工作场所和其它机构环境中提供的食物 中减少了盐的含量。与学校的儿童一 样，大多数成年人现在有绝大多部分时 间处在工作场所。因此，在这些环境中 保护和促进健康，包括减少盐摄入量， 是至关重要的20。 需要做什么 SHAKE提供了实用的方法，以便在 工作场所和其它机构环境中提供的食物 中减少盐分含量。它提供了初步的勘察 绘图支持，以便帮助各国确定证据表明 策略将产生最大影响的关键环境——例 如学校、工作场所、医院和饮食店。然 后，它提供了一系列经过验证的策略， 用于在这些环境中促进健康饮食（例如 为学校和工作场所提供的膳食制定标 准），以及社区环境中的行为改变干预 措施。 21 SHAKE还包括跨部门的指导，例如可 以在公共餐饮业中减少使用盐的监管变 化，并显示了若干国家如何制定和执行了 在学校和医院销售的食品中盐的最高许可 含量标准。最后，SHAKE纳入了世卫组织 其它有关指导的内容，例如向儿童推销食 品和饮料方面的建议。限制向在校学生推 销高盐食品，将从早年为健康饮食创造支 持性的环境，并将在今后数代人中产生长 期的积极健康行为21。 通过将所有这些因素结合在一 起，SHAKE一揽子计划提供了基于世界 各地现有做法的一整套政策工具。结合 强有力的政治承诺、良好的规划管理、 伙伴关系网络和有效的宣传，SHAKE可 以帮助任何国家制定健全的战略来减少 盐消费，从而帮助全球人民改变吃盐的 习惯。 22 虽然SHAKE一揽子计划的每个部 分都很重要，但是有若干核心要素将各 部分连接起来，而且这些要素将影响成 功。这些交叉领域包括政治承诺、规划 领导力、伙伴关系、与消除碘缺乏症规 划相结合以及宣传。 政治承诺 政治承诺对于启动和多年维持全民减 盐规划至关重要，而且为了规定明确的 任务和确保提供足够的资源，也是必不 可少的。专业团体、非政府组织、学术 界和消费者团体可以游说政府和政策领 导人提高对减盐在公共卫生议程中重要 性和可行性的认识。 附件1：成功的 减盐规划的要素 23 规划的领导和管理 制定减盐规划时最重要的决策之一是 决定由谁负责确保有效地实施规划。如 果有政府内部的高级别领导，减盐规划 最有可能取得成功。理想情况下，规划 应由对该问题具有特定兴趣的部长级指 定人员领导，并有足够的辅助人员和预 算来管理规划的日常运作。在制定食品 盐分含量目标时，这对促进行业部门遵 规尤其重要。有效的政府领导小组还应 该能够获取民间社会和行业部门其它利 益攸关群体的支持。如果不能由政府领 导，一个非政府组织或民间社会团体可 以在政府的支持下领导这项工作。 宣传 宣传是指开展活动，旨在使减盐成 为政治和发展议程上的主要问题，促进 政治意愿，增加用于制定规划的财政资 源和其它资源，以便确保实施工作可以 持久。宣传团体可以要求当局和行业组 织负责确保履行承诺和取得成果。虽然 任何人都可以倡导减盐，但集体行动比 24 孤立的努力更有可能奏效。相互关联和 互补的利益攸关方的广泛联盟可以促进 对话、谈判和共识，从而提高认识并加 强减盐行动。领导小组应力求获得利益 攸关方和咨询小组在一切可能方面的支 持。 伙伴关系 采用多部门和众多利益攸关方参与 的方法，加上政策领导人、其它政府部 门、非政府组织、消费者团体、医学 界、学术界和食品行业之间的强大网 络，可以为减盐议程提供强有力的支 持。在制定、实施和评价规划的整个过 程中，可以由一个咨询小组支持该规 划。咨询小组提供了机会，以便与不直 接参与规划领导工作的不同利益攸关方 进行接触并利用其专门知识和兴趣。咨 询小组成员必须对食品行业有充分的了 解，并与大量关键行业代表及其它利益 攸关方有良好的工作关系。 25 与消除碘缺乏症规划相结合 需要与负责消除碘缺乏症政策的人员 采取协调一致的做法，为减盐确保政策 一致性并维持政治支持。一个可信赖和 基础广泛的咨询小组可以为政府领导人 提供指导和支持，汇集减盐和消除碘缺 乏症领域内的利益攸关方，以便确保降 低人口盐消费水平不会对消除碘缺乏症 规划产生不利影响，而且促进碘盐不会 影响减盐工作。为了整合这两项行动， 重点领域包括政策制定、宣传和倡导、 监测和监督以及研究。 26 参考文献 1 https://www.washingtonpost.com/news/to-your-health/wp/2014/08/14/salt-intake-is- too-high-in-181- of-187-countries-around-the-world/，2016年6月3日访问。 2 Berry S。盐：食物中单一最有害的物质？《悉尼先驱晨报》。2014年8月19日（http://www.smh. com. au/lifestyle/diet-and-fitness/salt-the-single-most-harmful-substance-in-food- 20140816-104tun.html，2016年6月3日访问）。 3 He FJ，MacGregor GA。减盐可降低心血管风险：结果试验的汇总分析。《柳叶 刀》2011;378(9789):380-2（http://www.thelancet.com/pdfs/journals/lancet/PIIS0140- 6736(11)61174-4.pdf，2016年6月3日访问）。 4 少盐益寿。El Litoral。2014年3月22日（西班牙文）（http://www.ellitoral.com/index.php/ diarios/2014/03/22/nosotros/NOS-05.html，2016年6月3日访问）。 5 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H等。1990-2010年对 21个地区中因67种风险因素和风险因素集群导致的疾病和伤害负担的比较风险评估：为2010年 全球疾病负担研究进行的一项系统分析。《柳叶刀》，2012;380(9859):2224-60。 6《2008-2013年预防和控制非传染性疾病全球战略的行动计划》。日内瓦：世界卫生组织；2008 年。 7 Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F。对阿根廷布宜诺斯艾 利斯减少心血管疾病的一揽子干预措施进行的通用成本效益分析。成本效益和资源调拨：C/E. 2009;7:10。 8 Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S等。国家饮食和营养调查--评估 英国成年人（19至64岁）膳食中的钠，2011年。伦敦：卫生部，2012年。 9 指南：成人和儿童钠摄入量。日内瓦：世界卫生组织；2012年。 10 Powles J, Fahimi S, Micha R, Khatibzadeh S, Shi P等。1990年和2010年全球、区域和国家 的钠摄入量：24小时尿钠排泄的系统分析和全球饮食调查。BMJ Open. 2013;3e003733。 11 Horton R。离线：慢性病 - 我们时代的社会正义问题。《柳叶刀》，2015;386(10011):2378。 12 Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R。预防慢性疾病：减少盐分摄入 和控制烟草使用战略的健康影响和经济费用。《柳叶刀》，2007;370(9604):2044-53。 27 13 Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodrigues-Fernandex R等。世界各 地的减盐行动——对全球目标进展的系统审查。PLoS One. 2015;10(7):e0130247。 14 Mattes RD, Donnelly D。膳食钠源的相对作用。美国營养学院期刊。1991;10(4) 383-93。 15 He FJ, Brinsden HC , MacGregor GA。英国的盐减行动：公共卫生方面的成功实验。人类高 血压期刊。2014;28:345-52。 16 美洲的非传染性疾病：创建更健康的未来。华盛顿（特区）：泛美卫生组织；2011年。 17 Alhamad N, Almalt E, Alamir N, Subhakaran M。海湾合作理事会国家减少盐摄入量工作概 况。心血管病诊断治疗期刊。2015;5(3):172-7。 18 A/RES/66/2号决议，预防和控制非传染性疾病问题大会高级别会议的政治宣言，纽约：联合 国；2012年。 19 从负担到“最合算的措施”：在低收入和中等收入国家降低非传染性疾病的经济影响。日内瓦： 世界卫生组织；2011年。 20 Shain M, Kramer D。工作场所的健康促进：制定概念，审查证据。职业与环境医学杂 志。2004;61(7):642-8。 21 实施关于向儿童推销食品和非酒精饮料的一系列建议的框架。日内瓦：世界卫生组织；2012年。 28
WHO/NMH/PND/16.4 改变吃盐的习惯