Mandatory Salt-Reduction Targets, South Africa: Urban Food Policy Snapshot

Part of the Food Policy Snapshot Series

Food Policy: Mandatory Salt-Reduction Targets, South Africa

Overview: Increased consumption of sodium is a risk factor for noncommunicable diseases (NCDs) such as hypertension, which can increase an individual’s susceptibility to strokes and heart disease. In South Africa, there is a severe issue surrounding the consumption of salt. Within the nation, it is estimated that the citizens consume 2-3 times the daily recommended five grams of salt.

In 2013, the South Africa Study on global AGEing and adult health (SAGE) reported that South Africa has the highest rate of high blood pressure reported among individuals who are 50 and older. It has a higher rate of those with high blood pressure among this age group than any other country, at any time in history, with a rate of almost eight out of ten (77.9 percent). To work towards overcoming this severe issue, there has been a two-pronged plan created. It is comprised of both legislation and a consumer awareness program called Salt Watch.

Location: South Africa

• Population: 54, 956, 920 (2015)

Food policy category: Diet & Nutrition; Food Supply & Distribution; Preventative Health Care

Program Initiated: 

• In March 2013, the Minister of Health, Dr. Aaron Motsoaledi, decided to create numerical goals for salt reduction in thirteen food categories with expected gradual compliance by the years 2016 and then 2019. This would allow companies gradual time to reduce the amount of sodium in their products. During World Salt Awareness Week in 2013, at the first South African Salt Summit, Salt Watch was announced as a new multi-sectoral advocacy group, supported by the National Department of Health and led by the HSFSA and responsible for implementation of the national consumer awareness campaign. The intended goal from this campaign is to raise awareness and increase knowledge regarding the drawbacks of too much sodium in individuals’ diets. Together, these were created with the intention of reducing this problem.

Progress to date:

• Due to South Africa eliminating iodine deficiency through the process of fortifying salt, it is essential that both iodine and sodium levels are measured throughout the process.
  • The ratio of sodium to potassium levels may determine cardiovascular disease, rather than just sodium levels which is important to note. It is also going to be important to note whether legislation is more effective than the voluntary approach adopted by most countries. To study this relationship, it will be important to compare between countries that have, and do not have, laws regulating the amount of salt in food products.

• Thus far, The Heart and Stroke Foundation South Africa (HSFSA) states that there is self-reported good compliance with the first deadline on the part of large food manufacturers. However, during a salt consultation meeting September 2, 2016, inconsistencies were found between self-reported sodium levels and independent chemical analyses. Therefore, further research is being conducted in a wider range of products. In the next step of the process, the National Department of Health is going to meet with both laboratory managers and food companies to better comprehend the methodological issues with content food analysis. This is being completed in the hope that it will increase the effectiveness of implementation and monitoring.

Program goals:

• Address sodium levels in food, as well as the amount of salt added by individuals. On top of this, the awareness campaign and legislation are attempting to change the attitudes, behaviors and perceptions surrounding the commodity.
  • Through this, hopefully the rate of NCDs, which were responsible for about 43.4 percent of deaths in South Africa in 2012, will lower. Within this group, cardiovascular disease is the main cause of death, for which, as previously stated, an increased rate of sodium intake is a risk factor.
• That healthcare professionals will play a role in disseminating the information.

Overall program goals in regards to the thirteen food categories:

*Some amendments to these sodium targets have been proposed and the cut-offs for a few food products, like some of the savory snacks and processed meats, will be amended slightly, however, the NDoH believes that these changes are minor and do not adversely affect the public health of the population

How it works:

Legislation:

• Sodium levels in food will be checked to make sure that companies are complying with the standards.
  • Breads’ sodium levels will be checked via atomic absorption spectrometry with a toleration level of 10 percent.
  • All other foods will be checked by flame atomic absorption spectroscopy and/or Inductively Coupled Plasma analyses.
• For any company caught not abiding by the regulations, there will be a fine and penalties.
  • This will be handled via safety environment officers at a municipal level.

Awareness Program:

• The National Awareness Campaign during 2014/2015 consisted of two main elements: 1) an advertising campaign and 2) various supporting activities aimed at strengthening the advertisement message and providing additional information and education materials regarding salt reduction.
• The campaign ran from August 2014-May 2015.
• It was funded by the National Department of Health and consisted of 1 television and 2 radio advertisements.
  • They were translated into three commonly spoken South African languages. Sign language was also utilized in the television advertisements
• The four-month advertising campaign featured a well-known South African medical doctor and media personality who emphasized the message that South Africans are consuming too much salt and that too much salt leads to hypertension, which can cause heart attacks and strokes.
  • The doctor further urged South Africans to reduce their discretionary salt intake and ask their local clinic or doctor for more information.
• Supporting activities implemented included the launch of a Salt Watch website in line with the start of the advertising campaign in August 2014, which housed a mobile site function that utilised unstructured supplementary service data (USSD) technology that enabled the public to engage with Salt Watch in order to obtain more information and reduced-salt recipes.
• Salt Watch brochures were developed and translated into five different languages for distribution, free of charge through various platforms including free HSFSA public health screenings and wellness days.
• Further awareness activities made use of the HSFSA infrastructure and existing media relationships.  
  • Eight media releases were shared at regular intervals throughout the campaign generating numerous radio and television interviews, print and online articles.
• The HSFSA further dedicated their social media platforms to salt reduction messaging, including Facebook, Twitter and their monthly newsletter titled Heart Zone.
• Through a partnership with a local pharmaceutical company, the HSFSA launched a second edition of their recipe book Cooking from the Heart which contained 36 reduced-salt recipes, in addition to general healthy eating information and specific salt reduction messaging.
  • The recipe books were distributed free of charge via health care professionals.
• Healthcare professionals were engaged through various platforms including presentations and/or exhibitions at relevant congresses and meetings, a medical journal editorial, continued professional development articles and informative e-mails sent by professional associations/societies to their members.

Why it is important:

• It has been estimated that 60 percent of salt intake in South Africa is contributed by processed foods; however, this means that approximately 40 percent of salt intake is discretionary salt. Discretionary salt is sodium that individuals add to their food while cooking or to already prepared meals. Unlike many developed countries where salt intake is predominantly coming from the food supply, in South Africa individual behaviors and habits also significantly contribute to total salt intake. Both the food supply as well as consumer behavior therefore will be addressed through this campaign, hopefully resulting in different attitudes towards sodium intake.
  • Population wide salt reduction strategies are one of the most cost-effective interventions to reduce the growing burden of chronic diseases in most countries.
• This program could lead to a greater awareness among the general population about the link between high salt intake and health, the importance of reducing sodium (salt) intake and providing tools to do so.
• Reducing salt intake could furthermore provide economic benefits to South Africa on a country and individual level.
• Apart from the health benefits, there would be great financial outcomes for South Africa as well.
  • There would be a total annual savings of 40 million US dollars in regards to preventing non-fatal strokes.
  • With the reduction of sodium in bread, this would conclude in an 80% cost savings.
  • There would also be significant individual household savings.

Evaluation:

• The awareness campaign was evaluated through community-based, in-home surveys with 477 black African women, aged 18 – 55 years in three provinces in South Africa.  A significant positive change in reported knowledge, attitudes and behaviors was found including significant shifts in reported actions to reduce salt intake.
  • Even though the campaign evaluation had limitations in relation to tracking sustained knowledge and behavior change over time, the findings strongly suggest that mass media campaigns complement the legislation and other NDoH efforts to reduce salt intake in South Africa.

Learn More:

• www.heartfoundation.co.za

Point of Contact:

Gabriel Eksteen, Heart and Stroke Foundation South Africa: gabriel@heartfoundation.co.za

Similar Practices:

• A systematic review by Trieu et al. (2015) aimed to track salt reduction initiatives around the world.  An increase in initiatives was seen globally compared to a similar review by Webster et al in 2010, with strategies in all six WHO regions. Ninety-three percent of countries make use of more than one strategy (ie food reformulation, consumer education, front of pack labelling, interventions in public institution settings)

• 36 countries make use of voluntary targets, nine countries have mandatory maximum sodium levels (mostly bread)
• Argentina, Bulgaria, Greece and South Africa have additional limits for other foods.
• Strategies in Africa remain very limited with South Africa taking the lead.
• 12 countries reported change in population salt intake, ranging from 5 – 36 percent
  • However, these results should be interpreted with caution

References:

A big thank you to the Heart and Stroke Foundation South Africa and South African National Department of Health who provided information regarding this Food Policy Snapshot and different articles for further research

https://data.worldbank.org/indicator/SP.POP.TOTL?locations=ZA

https://www.worldactiononsalt.com/worldaction/africa/73487.html

https://www.health24.com/Medical/Hypertension/Lifestyle-changes/south-africans-to-eat-less-salt-as-new-law-kicks-in-20160630

https://www.afro.who.int