Hypertension is the primary risk factor for cardiovascular disease (CVD), the leading cause of death worldwide . Dietary risk factors are a major cause of hypertension, with approximately 500 million cases of hypertension, over 44 million disability-adjusted life years lost and over 1.8 million deaths attributable to high dietary sodium (the leading dietary risk) in 2019 . Given the high and ever-increasing burden of CVD, it is important to renew and continually strengthen efforts to mobilize resources to address key risk factors, especially in the face of other pressing health issues such as the COVID-19 pandemic.
Reducing dietary sodium intake is a WHO ‘best buy’ for governments to improve population health and reduce non communicable diseases (NCD)s . Resolve to Save Lives (RTSL) partners with the World Health Organization (WHO) in its effort to reduce NCDs and has established dietary sodium reduction as one of its three pillars to improve cardiovascular health [3, 4].
To aid countries in developing, enhancing, and evaluating dietary sodium reduction programs, RTSL developed and released a new web-based resource called the Sodium Reduction Framework in December 2021 . The Framework was developed by an RTSL expert team and reviewed by nutrition specialists in RTSL country offices with sodium reduction programs and external expert partners with experience implementing national sodium reduction programs globally. The aim of the Framework is to provide an overview of the key components of sodium reduction programs, linking to both previously developed and established guidance and providing numerous country and regional examples.
The Framework identifies two main components for all sodium reduction programs, as well as three key avenues for sodium reduction interventions. The first two components, which should be present in all sodium reduction program considerations, are Governance and Surveillance, described below. The Framework then provides overviews of specific interventions which target packaged foods, food prepared outside the home, and sodium added in the home. The final section of the framework is an appendix which includes a number of interactive tools for monitoring and planning.
For each component, several key steps are briefly outlined. The steps identified for the first component, Governance, are performing a situational analysis, establishing the health and economic benefits of the sodium reduction program, setting short-, medium-, and long-term goals for dietary sodium, establishing an operational plan, designing and conducting advocacy, engaging stakeholders and mitigating conflicts of interest. For Surveillance, the key steps are identified as developing a surveillance, monitoring and evaluation plan, collecting sodium indicator data, ensuring program transparency and accountability and using the data to drive regular program review. The section on interventions for packaged foods includes guidance on developing nutrient profiling models, labeling interventions (e.g., front-of-package warning labels), targets and timelines for the reducing sodium content of packaged foods, marketing restrictions to children, fiscal policies (e.g., taxes on high sodium foods) and other less tested but innovative interventions (e.g., prohibiting sales of unhealthy food to children). The section on food prepared outside the home includes healthy public food procurement policies and interventions for restaurants and street foods. The section on sodium added in the home includes behavior change interventions, increasing the use of low sodium salts and other less tested but innovative interventions (e.g., warning labels on salt containers, standardized spoons for dispensing salt). Under each section, users will find links to other existing resources previously developed on the respective subjects, such as key implementation tools developed by the WHO or other experts, country examples, and other related resources. The appendices include: an interactive checklist meant to aid in program monitoring, a sample situational analysis for preparing a sodium reduction strategy, and an adapted guide from the Global Food Monitoring Group on how to develop a packaged food database.
The framework is unique in that it provides a comprehensive overview of the most current sodium reduction policy options available. This includes interventions across the spectrum of evidence levels, from well-established and highly recommended WHO-endorsed interventions which have been tried, tested, and found to be successful with substantive evidence through research and country examples, to more novel interventions which are promising and are under investigation for substantive effectiveness. The framework itself, as well as the linked additional resources, are updated in real time as new resources are developed and new evidence is identified for or against certain strategies in sodium reduction programming. Also, the Framework includes a survey to provide an opportunity for users to further enhance the program in subsequent updates. Users are highly encouraged to provide feedback, making the framework a living resource, or in other words one which can be quickly and easily made up to date with new research findings and/or country progress.
The intended impact of this newly developed resource is to centralize the available information and guidance on dietary sodium reduction programs across all available country and regional contexts, while both aligning with global official guidance and creating space to explore newer strategies in development. It is intended to be useful at multiple stages of developing sodium reduction programs, whether by giving an overview of current policies and strategies in place for those in the early stages of planning programs, providing options for strengthening an existing sodium reduction strategy, or providing tools for evaluating current programs which are being implemented. Additionally, the interactive checklist provided in the appendices is a useful tool in monitoring current programs, identifying gaps in national strategies, and providing direction for prioritization in future programs and strategies. It is hoped that this Framework for developing and monitoring sodium reduction programs will help the development of sodium reduction policies be more cohesive and aligned globally, thereby having a tangible impact on population sodium reduction and ultimately reducing the burden of CVDs.
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NC reports personal fees from Resolve to Save Lives (as do NAG, NI, LC, and RG), the Pan American Health Organization, and the World Bank outside the submitted work; and is an unpaid member of World Action on Salt, Sugar and Health and an unpaid consultant on dietary sodium and hypertension control to numerous governmental and non-governmental organizations including the World Health Organization. NC chaired the International Consortium for Quality Research on Dietary Sodium/Salt (TRUE) which is an unpaid voluntary position.
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Abdel-Gawad, N., Campbell, N.R.C., Ide, N. et al. The resolve to save lives sodium reduction framework; aligning global efforts to reduce the global burden of cardiovascular disease. J Hum Hypertens (2022). https://doi.org/10.1038/s41371-022-00745-2