Mobilizing champions for sodium reduction in Thailand

Excess sodium consumption is directly related to hypertension and kidney disease,1Malta D. Petersen K.S. Johnson C. et al.High sodium intake increases blood pressure and risk of kidney disease. From the Science of Salt: a regularly updated systematic review of salt and health outcomes (August 2016 to March 2017).J Clin Hypertens. 2018; 20: 1654-1665Crossref Scopus (82) Google Scholar increasing cardiovascular disease and death.2Ma Y. He F.J. Sun Q. et al.24-Hour urinary sodium and potassium excretion and cardiovascular risk.N Engl J Med. 2022; 386: 252-263https://doi.org/10.1056/NEJMoa2109794Crossref PubMed Scopus (128) Google Scholar However, sodium intake remains high in populations worldwide, and relatively few low- and middle-income countries (LMICs) have implemented comprehensive policies addressing sodium consumption.3World Health OrganizationWHO global report on sodium intake reduction. World Health Organization.https://www.who.int/publications/i/item/9789240069985Date: 2023Google Scholar The Thai Low Salt Network (LSN), formed in 2012, is an effective, multi-disciplinary partner network that inspired Thailand's sodium reduction efforts. Building a strong, diverse coalition with effective leadership successfully influenced policymakers to take action and created a broad social movement to reduce sodium intake. We aim to provide a model to other countries to develop similar champion networks to advocate for and implement sodium reduction strategies. The LSN was formed in 2012 as a civil society organization under the Thai Health Promotion Foundation (ThaiHealth). A practicing nephrologist leads the network, mobilizing funding and recruiting a multidisciplinary group of voluntary members, including nephrologists, dieticians, public health researchers and communication officers. The LSN had two initial aims, (1) to provide public education on salt reduction and (2) to conduct research for policy advocacy, which expanded to direct policy advocacy. These efforts set the stage for government action: in 2015 salt reduction was adopted as a priority to reduce non-communicable diseases (NCDs),4National Health Commission Office: ThailandThailand 8th National Health Assembly. 8/Main 4: policy on reduced salt and sodium consumption for NCD reduction. National Health Commission Office: Thailand.https://en.nationalhealth.or.th/wp-content/uploads/2017/09/4_1salt-sodium-main.pdfDate: 2015Google Scholar and in 2016 a strategic plan set a goal of achieving a 30% reduction in salt intake by 2025, aligned with the WHO's global target.5Department of Disease Control, Ministry of Public Health of ThailandStrategy to reduce salt and sodium consumption in Thailand. National Health Commission Office: Thailand.http://thaincd.com/document/file/info/non-communicable-disease/ยุทธศาตร์ลดบริโภคและโซเดิมฯ.pdfDate: 2016Google Scholar In its first decade, the LSN and its partners successfully advocated to place salt reduction on the government's agenda, mobilize national-level commitments and a strategic plan, and maintain momentum over time. The LSN generated public awareness on the importance of salt reduction, garnered support from government and key stakeholders for salt reduction, generated data on sodium intake and sodium content in foods, developed innovative strategies for monitoring sodium content and on reducing sodium in packaged foods and prepared dishes, and supported the initiation of activities to develop polices on taxation of high salt foods, marketing restrictions, front-of-package labeling, public food procurement and service, and setting salt targets for key packaged foods (see Fig. 1). The LSN has been guided by the WHO SHAKE technical package for sodium reduction and the national strategic plan. Key factors for success include: The national commitment to sodium reduction and the strategic plan established sodium reduction as a national priority. Financial support from ThaiHealth and, more recently, WHO Thailand and Resolve to Save Lives has expanded LSN's reach. The LSN developed a strong network of collaborative partners across diverse fields including government agencies, finance, academia, professional societies, and civil society, as well as collaborations with complementary NCD- and food-related national initiatives and committees. In 2020, the LSN led a nationally representative survey to estimate dietary sodium consumption using 24-h urinary analyses,6Chailimpamontree W. Kantachuvesiri S. Aekplakorn W. et al.Estimated dietary sodium intake in Thailand: a nationwide population survey with 24-hour urine collections.J Clin Hypertens. 2021; 23: 744-754https://doi.org/10.1111/jch.14147Crossref Scopus (14) Google Scholar finding an average dietary sodium intake of 3.636 mg per day (9.1 g salt). The LSN plans to repeat this study every 5 years to evaluate salt reduction strategies. The LSN also worked with academic partners to measure the sodium content of Bangkok street food7Vatanasuchat N. Tanjor S. Pukasmas U. et al.A study on sodium and sodium chloride content in street foods sold in Bangkok for the year 2017.https://www.lowsaltthai.com/download-%E0%B8%87%E0%B8%B2%E0%B8%99%E0%B8%A7%E0%B8%B4%E0%B8%88%E0%B8%B1%E0%B8%A2-52587.pageGoogle Scholar and collects data annually on the sodium content of packaged food. This evidence, along with data on the economic impact of high sodium intake through an investment case analysis,8Ministry of Public Health of ThailandThe World Health Organization (WHO)The United Nations Development Programme (UNDP)The United Nations Inter-Agency Task Force (UNIATF) on the Prevention and Control of NCDsPrevention and control of noncommunicable diseases in Thailand – the case for investment. United Nations.https://thailand.un.org/sites/default/files/2021-11/%E6%9C%80%E6%96%B0%EF%BC%BFTHAILAND_NCD%20IC%20REPORT_v06_231121.pdfDate: 2021Google Scholar have been instrumental to making the case for sodium reduction. The LSN has supported innovative research to generate locally appropriate strategies to replace sodium in packaged foods9Mekhora C. Vattanasuchart N. Sodium reduction: health role, strategy and research for food product reformulation.J Nutr Assoc Thailand. 2020; 55: 111-125Google Scholar and developed a salt meter and urine strip for the public to monitor their salt intake.10Wiriyatanakorn S. Mukdadilok A. Kantachuvesiri S. Mekhora C. Yingchoncharoen T. Impact of self-monitoring of salt intake by salt meter in hypertensive patients: a randomized controlled trial (SMAL-SALT).J Clin Hypertens. 2021; 23: 1852-1861https://doi.org/10.1111/jch.14344Crossref Scopus (5) Google Scholar The LSN and partners implemented targeted public awareness campaigns on the dangers of high salt intake and strategies for salt reduction via television, radio, press, and social media, which motivated the reformulation of some packaged foods, including instant noodles and condiments. The LSN also launched a campaign and website to promote restaurants that reduced sodium in their recipes. The LSN, in collaboration with government and other partners, has supported policy proposals to reduce sodium in packaged foods and public environments through improved packaged food labeling, fiscal policies (taxes) for high salt foods, target setting, child-directed food marketing restrictions, and healthy public food procurement policies. The LSN is highly effective in mobilizing a multi-disciplinary group of champions who remain committed to sodium reduction. The approach is comprehensive, targeting all sources of sodium including packaged foods; food eaten outside the home; and salt and condiments used in home cooking. To meet the goal of a 30% reduction in sodium intake, mandatory approaches are needed. So far, the food industry has been reluctant to participate in mandatory food regulation. Strong support from civil society and academia is essential to inspire commitments from policymakers to adopt mandatory policies. In its first decade, the LSN and its partners have generated public awareness, garnered support from government and key stakeholders, collected data on sodium intake and sodium content in foods, developed innovative strategies for monitoring sodium content and sodium reformulation, and supported the consideration of key nutrition polices. Building multi-disciplinary stakeholder networks can support national action on sodium reduction.