Three quarters of our daily salt intake comes from prepared and manufactured foods.

Experts suggest that the most effective approach to reducing salt consumption in a population is to more actively regulate the amount of salt in prepared foods.

However, there is a debate about the best strategy to curb salt intake in Canada.

Does Regulating Salt lead to a Bad Taste in Canadians’ Mouths?

While there is some debate about the impact on health care outcomes of reducing salt intake at the population-level, there is little doubt that high levels of sodium contribute to high blood pressure, which in turn increases the risk of heart disease, kidney disease and stroke. A recent paper in Nature made a very powerful argument for the regulation of another food ingredient, sugar, which is a key driver of diabetes, cardiovascular and fatty liver disease.

Some believe the best way of decreasing the salt intake of Canadians is through more public education and voluntary efforts by industry. Others argue that more active federal regulation of salt content is needed to reduce Canadians’ salt consumption.

Yoni Freedhoff, an obesity medicine specialist in Ottawa says that “Politically these issues [of regulating salt] are not palatable” and argues that many Canadians “see the involvement of Health Canada in food as nannyism and intrusion.” However, he argues that “It is supposed to be our government’s job to protect our health and health care system, which is being crushed by burden of diet-related chronic diseases.”

What options are available for the federal government to regulate salt intake?

The Health Canada Sodium Working Group

In 2007 Health Canada established the Sodium Working Group, which was made up of twenty-five experts from food manufacturing and service industry groups, public health non-governmental organizations, researchers, consumer advocates, health professionals and government representatives.

Bill Jeffrey, National Coordinator at the Center for Science in the Public Interest, who was a member of the Working Group says “at the time it was considered a victory that with so many industry representatives on the Working Group, we were able to make unanimous recommendations.”

The Working Group provided six overarching recommendations, mostly aimed at Health Canada, to try to reduce the amount of salt Canadians consume. They provided more specific recommendations about food supply regulation, education, research and evaluation. The recommendations included:

• setting an interim goal to reduce salt consumption from an estimated average of 3400-4000 mg per day to 2300 mg per day by 2016,
• setting voluntary salt reduction targets for the food industry, a commitment from the food industry to meet these targets, and government oversight to determine whether the targets are being achieved,
• improved food labelling so Canadians can better understand the salt content of processed and restaurant foods,
• education programmes for Canadians, governments and those involved in the food sector about salt intake,
• support for research around salt, focused on health impacts, food science and regulatory issues.

These recommendations were delivered in July 2010. Health Canada has, to date, made no commitments on targets for reducing salt intake. Within a year of the report’s release the Working Group was disbanded.  Health Canada was contacted for comment, but did not reply by press time.

Bill Jeffrey says “the federal government has an anti-regulation bias and it seems that they are so against public health regulations that they do not care what the consequences are in terms of possible lives saved or financial consequences to the health system and economy.”

Reaction from Industry

Derek Nighbor from Food & Consumer Products Canada, the association representing the food industry, believes the goals of the Sodium Working Group were admirable, but that its aggressive target of a 30% reduction in sodium in only 5 years was not realistic.  “Reformulating products is not something a manufacturer can do overnight.  Reformulation is time consuming and resource intensive – and the public’s palate needs time to adjust as well.”

Nighbor insists the food industry is on board with sodium reduction, saying “We’re not ‘sodium deniers.’  Industry absolutely recognizes the public health imperative of reducing Canadians’ sodium intake.”  Industry favours a voluntary approach to regulation, which would allow companies to market both higher sodium and lower sodium foods to a “Sales Weighted Average.”  Nighbor explains, “This approach allows companies to focus their efforts on products Canadians are eating the most of.  If companies are able to significantly reduce sodium in their most popular products first, the net impact is going to be bigger and faster than if they have to reformulate every product they make at once.”

Kevin Willis, director of partnerships for the Canadian Stroke Network argues that “there is a competitive disadvantage [for food manufacturers] in making changes”. He says “what is really needed is a comprehensive and concerted approach across the food supply which levels the playing field for companies… and with regulation to back up this approach.”

Lessons from Abroad & Options Available to Government in Sodium Regulation

High salt intake is a global problem, and different countries have taken different approaches to regulating, limiting and reducing salt intake.

Some governments have chosen to take a ‘structured voluntary approach’ where the food industry voluntarily collaborates with government to reduce the amount of salt added to food. The United Kingdom took this approach after the publication of the Scientific Advisory Committee on Nutrition Report in 2003, which found alarming rates of salt consumption. Recommendations were put in place to work with the food industry to reformulate food and reduce salt content, and to launch a public awareness campaign to reduce salt intake. Evidence indicates that this approach has had a modest influence, decreasing daily intake from an average of 3800 mg per day in 2001 to 3440 mg per day in 2008.

Since the 1970s Finland has worked to reduce salt intake in its citizens. Working with industry, salt intake has fallen by a third over 30 years. During this same period of time systolic blood pressure fell and mortality from stroke and coronary heart disease decreased 75-80%. Similarly, Japan mounted a government campaign to reduce salt intake, which was associated with a fall from 5400mg to 4840 mg sodium in a decade, along with a substantial reduction in stroke mortality.

Some countries have taken a harder stance. In Portugal, for example, a group of doctors initiated a public awareness campaign and lobbied the government to regulate processed foods, following well-publicized studies about the amount of salt in the country’s staple food – bread. The campaign led to the Portuguese Parliament passing laws restricting the amount of salt in bread and other processed food. A public education campaign was also put in place around salt intake. In 2009, a survey found that 59% of the Portugese public associated salt with high blood pressure, 44% had changed their salt consumption, and 25% had substantially reduced their salt intake during the previous year.  In the case of Finland, Japan and England, public led campaigns with the support of government appear to have contributed to lower sodium consumption, one of the factors associated with reduced disease burden.

The role of government in public health regulation

Despite some concerns that regulating salt is an infringement of government on individuals’ personal autonomy, there are many examples where government regulations have helped save lives. Two recent examples of public health policies at the provincial level are seat belt and smoking laws. Both these initiatives have improved the health and survival of the population. They were put in place without randomized trials supporting their efficacy, and the public health interventions were modified (eg. the introduction of regulations about smoking in public places) as the evidence about the benefits and social acceptability of these interventions grew. In both cases, making the healthier choice the default option made it easier to exercise a healthy choice than an unhealthy one.

Is there enough evidence, or proof of concept, for similar public health efforts to be undertaken to reduce salt intake in Canada?