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HRF Help Desk Request

Title: Discussion Paper Solomon Islands Nutrition - November 2013Authors: Heather Grieve, Kate Mellor, Dr Julie Brimblecombe, and Jenny Busch Hallen

Menzies School of Health ResearchDate: 13 November 2013

1. Background

In September 2013 the AusAID Post in Solomon Islands requested support from the AusAID Health Resource Facility (HRF) to undertake a desk based review on a range of nutrition interventions to inform discussions about opportunities to improve nutrition in SI. The areas of particular interest outlined in the request included “recent innovations and emerging best practice in salt reduction interventions and food fortification programs in aid interventions” and “concepts trialled in the Asia-Pacific both for improving micronutrient deficiency in children and in response to NCD epidemic”.

HRF requested technical assistance from Menzies School of Health Research (Menzies) to respond to this request. In September 2013 a teleconference between Menzies, HRF and AusAID Solomon Islands to clarify the background and scope of the request was conducted. It was agreed that the review would consider programmes that involve public private partnerships (as recommended by the Government of Solomon Islands (GoSI)), focusing on programmes that do not require significant human resource input from the GoSI due to current limitations in human resource capacity.

This discussion draft discussion paper was prepared in readiness for a meeting between AusAID Solomon Islands and HRF in Honiara on 28 October 2013.

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Description of Request: Please identify recent innovations and emerging best practices in salt reduction interventions and food fortification programs in aid interventions particularly those implemented through the private (or NGO sector) sector. Particularly interested in concepts trialled in the Asia-Pacific both for improving micro-nutrient deficiency in children and in response to NCD epidemic and on learning what has worked and what has not and why. Particular opportunities likely to be considered by the program include grant funding to reduce salt levels in tinned tuna and fortifying white rice. Advice on how results were monitored and any relevant impact evaluations (including who completed them) would be very gratefully received.

2. Methodology

A desk-based literature review was complemented by personal communication with AusAID Solomon Islands and the World Health Organisation (WHO) in Fiji and the Solomon Islands. Information was also drawn from existing knowledge of programs and activities in countries in Asia and the Pacific.

Draft recommendations for discussion were developed based on the information collated.

3. Global Nutrition Landscape

Recognising the critical need to improve nutrition, particularly during the critical period from pre-conception to 24 months of age, in order to achieve optimal health and development outcomes, the World Health Assembly (WHA) resolution 65.61 endorsed six global nutrition targets for 2025 under the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition:

1) Reduce stunting in children under five years by 40%2) Reduce anaemia in women of reproductive age by 50%3) Reduce low birth weight by 30%4) Maintain no increase in childhood obesity5) Increase exclusive breastfeeding rates in the first six months by at least 50%6) Reduce and maintain childhood wasting to less than 5%.

WHO calls for countries to adapt and translate relevant Global Targets at the national level considering the country nutrition profile, trends in risk factors and demographics, strength of the health system and nutrition policy development and implementation experience.2 Whist there are some data limitations in Solomon Islands, many of the Global Targets related to nutrition are relevant, in particular the targets related to stunting, anaemia, obesity and NCDs.

In May 2013, member states of the WHA endorsed a final draft of the Global Action Plan for the Prevention and Control of NCDs 2013-2020.3 The Plan includes nine Voluntary Global Targets:

1) A 25 % relative reduction in overall mortality from cardiovascular disease, cancer, diabetes or chronic respiratory disease

2) At least a 10% relative reduction in the harmful use of alcohol, as appropriate within the national context

3) A 10 % relative reduction in the prevalence of insufficient physical activity4) A 30% relative reduction in mean population intake of salt, with the aim of achieving a

target of less than 5 grams per day (equivalent to approximately 2g sodium/day)

1 World Health Assembly, Resolution 65.6, Maternal, infant and young child nutrition, http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_R6-en.pdf

2 Onis, Mercedes, et al. "The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions." Maternal & child nutrition 9.S2 (2013): 6-26.

3 World Health Assembly. Follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases,

http://ncdalliance.org/sites/default/files/rfiles/Final%20OR%20with%20GAP_A66_R10-en.pdf

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http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_R6-en.pdf

5) A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years

6) A 25% relative reduction in the prevalence of raised blood pressure (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) or contain the prevalence of raised blood pressure according to national standards

7) Halt the rise in diabetes and obesity8) At least 50% of eligible people receive drug therapy and counselling (including

glycaemic control) to prevent heart attacks and strokes9) An 80% availability of the affordable basic technologies and essential medicines,

including generics, required to treat major NCDs in both public and private facilities.

Given the burden of NCDs in Solomon Islands, each of these voluntary targets are highly relevant.

4. Nutrition profile of Solomon Islands

Solomon Islands is affected by a double burden of high rates of undernutrition in women and children, coupled with high rates of overweight and obesity in adults.

The most recent nutrition data indicate that undernutrition is a persisting public health issue for children and women in the Solomon Islands.4 33% of children under five years are stunted,5 a “high” prevalence according to WHO public health cut offs6 and a sign of long term chronic undernutrition in this age group. In addition, the prevalence of anaemia in children aged 6-59 months and non-pregnant women represents a “severe” public health problem7 with prevalence rates of 48% in children aged 6-59 months and 44% in non –pregnant women.8

At the other end of the spectrum, as in many other Pacific Island Countries (PICs), overweight and obesity amongst adults in Solomon Islands is a concern. 68% of adults over 20 years are overweight (Body mass index (BMI) ≥25kg/m) and 33% are obese (BMI ≥30kg/m2), with women more likely to be overweight and obese than men (73% versus 62.5% and 40.4% versus 28.5% respectively).9

Non-communicable diseases (NCDs) associated with overweight and obesity, including cardiovascular disease and type 2 diabetes, are the leading cause of death in Solomon Islands, accounting for an estimated 60% of deaths.10 The 2010 Global Burden of Disease report for Asia

4 It should be noted that much of the most recent nutrition data for Solomon Islands is from the 2006-2007 DHS, and most are in need of updating.

5 The 2013 World Health Organisation World Health Statistics reports that between 2005 and 2012, 32.8% of children under 5 years were stunted (more than 2 standard deviations below the mean height

for age)

6 WHO. Nutrition Landscape Information System: Country profile indicators guide. Geneva: World Health Organisation;2010

7 Ibid.

8 Solomon Islands National Statistics Office (SINSO), Ministry of Health (Solomon Islands), Secretariat of the Pacific Community (SPC), Macro International, Inc. Solomon Islands Demographic and

Health Survey 2006-2007. Noumea, New Caledonia, France: Secretariat of the Pacific Community (SPC).

9 Solomon Islands Ministry of Health and Medical Services, World Health Organization and Fiji School of Medicine: The Solomon Islands NCD Risk Factors STEPS REPORT. Suva, 2010

10 World Bank: World Development Indicator Tables; 2008

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and the Pacific states that type 2 diabetes is the leading cause of disability adjusted life years (DALYs) in Solomon Islands.11

Further to the high prevalence of overweight and obesity, WHO reports yearly increases in the prevalence of additional NCD risk factors, such as tobacco use and high systolic blood pressure, in Solomon Islands since the 1980s.12 42.4% of men and 14.4% of women over 15 years smoke tobacco on a daily basis,13 and almost a third (30.8%) of adults over 25 years have raised blood pressure (32.7% of men and 28.9% of women).14

(Please refer to appendix 1 for a detailed Solomon Islands nutrition and health profile)

4.1. Diet in the Solomon Islands

The Solomon Islands National Statistical office reports that over 80% of the population live in rural areas, and produce approximately 60% of their own food.15 Locally produced vegetables such as sweet potato, cassava, yam, banana, taro, breadfruit and corn are important staples for households in rural areas, as are other vegetables such as green leafy vegetables, pumpkin shoot, taro leaf and various bush greens.16 Imported processed foods are becoming more available in rural areas but the majority of households have limited buying power.17 In provincial urban areas and Honiara only 15% and 10% respectively of foods are locally produced.18 The most common processed foods available are instant noodles, flour, rice, canned fish and biscuits. 85% of total food imports are cereal products.

The intake of cereal products (excluding beer) was estimated to have increased significantly from 162g per person per day in 1992 to 254g per person per day; an increase of 92g/person/day (see figure 1).19

11http://www.healthmetricsandevaluation.org/sites/default/files/policy_report/2013/world_bank/WB%20GBD%20Report%2C%20East%20Asia%20%26%20Pacific.pdf

12 World Health Organization Western Pacific Region. Noncommunicable Diseases in the Western Pacific Region: A Profile: 2012

13 Ibid.

14 Ibid

15 Solomon Islands National Statistical Office 2008

16 Siliota C., Weinberger K. & Wu M. 2009. Baseline Report – Vegetable Production in Guadalcanal and Malaita, Solomon Islands December 2008. AVRCD – The World Vegetable Center. 21 pp., Cited

in Anderson, A.B., Thilsted, S.H., Schwarz, A.M. Food and nutrition security in Solomon Islands. March 25, 2013. Research program on Aquatic Agricultural Systems,

http://aas.cgiar.org/sites/default/files/publications/files/WF_3544.pdf

17 Solomon Islands National Statistical Office 2008

18 Ibid.

19 FAO, 2012 Food Security Data by Food Groups/items http://knoema.com/atlas/Solomon-Islands/topics/Food-Security/Food-Consumption/Cereals-Excluding-Beer

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http://knoema.com/atlas/Solomon-Islands/topics/Food-Security/Food-Consumption/Cereals-Excluding-Beer


Figure 1: Trends in food consumption in Solomon Islands (1992-2007)

The annual per capita consumption of rice more than doubled between 1990 and 2003, increasing from 30kg to 66.3kg, according to FAO estimates. The annual per capita consumption of wheat also more than doubled in the same time period, increasing from 7.9kg in 1990 to 17.5kg in 2003. 20

In contrast, per capita consumption of fresh marine fish has declined, dropping from 38kg per person per year in 2003 to 33kg per person per year in 2009.21.In 2009, the highest intakes of fresh marine fish were in urban areas and coastal rural communities.22 The decline in the consumption of fish and seafood is reflected in the most recent FAO food security data as shown in figure 2 below.23

20 Solomon Islands Government (2009) Draft National Food Security , Food Safety and Nutrition Policy 2010-2015

21 Solomon Islands Government (2009) National Food Security , Food Safety and Nutrition Policy 2010-2015

22 Bell J.D., Kronen M., Vunisea A., Nash W.J., et al. 2009. Planning the Use of Fish for Food Security in the Pacific. Marine Policy. 33: 64–76. And

Molea, T. & Vuki, V. 2008. Subsistence fishing and fish consumption patters of the saltwater people of Lau Lagoon, Malaita, Solomon Islands: A case study of Funaafou and Niuleni Islanders. SPC

Women in Fisheries Information Bulletin. 18: 30-35. This 2 references were cited in Anderson, A.B., Thilsted, S.H., Schwarz, A.M (2013)

23 FAO, 2012 Food Security Data by Food Groups/items

http://knoema.com/atlas/Solomon-Islands/topics/Food-Security/Food-Consumption/Fish-Seafood

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http://knoema.com/atlas/Solomon-Islands/topics/Food-Security/Food-Consumption/Fish-Seafood

Figure 2: Trends in fish and seafood consumption in Solomon Islands (1992-2007)

In urban areas most of the fish consumed is canned, due largely to the high cost of fresh marine fish.24 The commercial fishery sector of the Solomon Islands is mostly tuna fishing with an annual sustainable yield estimated to be 120,000 metric tons. The production of canned fish drastically declined in the early 2000s due to the closure of the Japanese canned fish manufacturing company, Taiyo. 25 Tuna fishing in Solomon Islands was scaled back, production declined by over 50% cent; and the value of formal fisheries exports dropped by 77%.26 In 2001, the government recommenced the entity, as Soltai Fishing and Processing, but it is unclear to what extent production has increased as a result. Anderson et al. also predict that “fish consumption will continue to decrease in the future due to shortfalls in supply from capture fisheries caused, for example, by poorly managed coastal resources and increasing population pressure.”27 It is noted in Solomon Islands’ National Food Security, Food Safety and Nutrition Policy that improving the food safety and quality aspects of production of the fishing industry is a priority for this sector.28

There is limited data on dietary salt intake in Solomon Islands. However the changing patterns of food intake from local foods to more processed imported and locally manufactured foods

24 Anderson, A.B., Thilsted, S.H., Schwarz, A.M. Food and nutrition security in Solomon Islands. March 25, 2013. Research program on Aquatic Agricultural Systems 2011.,

http://aas.cgiar.org/sites/default/files/publications/files/WF_3544.pdf.

25 Barclay, K. Tuna dreams revisited : Economic contributions from a tuna enterprise in Solomon Islands. Pacific Economic Bulletin, 2005; 20 (3):78

26 Central Bank of Solomon Islands 2001:18, 28

27 Anderson, A.B., Thilsted, S.H., Schwarz, A.M. Food and nutrition security in Solomon Islands. March 25, 2013. Research program on Aquatic Agricultural Systems 2011.,

http://aas.cgiar.org/sites/default/files/publications/files/WF_3544.pdf.

28 Solomon Islands Government (2009) National Food Security , Food Safety and Nutrition Policy 2010-2015

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(including bread, cakes, biscuits, chicken and canned fish),29 particularly in urban areas, provides some insight into the contribution of salt in the diet.30

4.2. National nutrition (& nutrition related) plans, policies, laws and regulations in Solomon Islands

The GoSI has developed the following plans and policies related to nutrition:

National Food Security, Food Safety and Nutrition Policy 2010-2015: a multi-sectoral policy developed and implemented jointly by Ministry of Agriculture; Ministry of Fisheries and Marine Resources and the Ministry of Health31. The Policy includes eight strategies:1. Sustaining integration of food security, food safety and nutrition2. Increasing agricultural and fisheries productivity in a changing climate3. Adding health value to food produced and processed within and imported into the

Solomon Islands4. Food standards that are harmonized with standards of other Pacific Island Countries and

with the Codex Alimentarius5. Scaling up efforts for better nutrition, particularly among the most vulnerable population6. Strengthening social marketing and awareness raising to increase the number of

consumers making safer and healthier food choices7. Strengthening research and appropriate technology development in primary production;

and 8. Increasing emergency preparedness and responsiveness.

The National Nutrition and Healthy Lifestyle Plan 2007-2017: a multi-sectoral plan that addresses nutrition and other NCD risk factors for the prevention and control of lifestyle diseases

“Kaikaim Lokol Kaikai” October 2013 (draft): a framework for action on the promotion of local food production.

The GoSI has endorsed the following nutrition related national laws and regulations:

The Pure Food Act, 1996: sets the overall legal framework for food quality and safety in Solomon Islands. The Act allows for development and implementation of food-related regulations.

Pure Food Regulations, 2010: endorsed in 2010 and are currently providing the legal framework (under the Pure Food Act 1996) for food quality and safety in Solomon Islands. The regulations are based on Codex Alimentarius food standards and cover issues related to food additives and nutritional supplements; packaging and apparatus; labelling and

29 Allen M.G., Bourke R.M., Evans B.R., Iramu E., et al. 2006. Solomon Islands Smallholder Agriculture Study – Volume 4, Provincial Reports. Australian Government – AusAID. 141 pp. Available online:

http://www.ausaid.gov.au/Publications/Documents/solomon_study_vol4.pdf

30 Anderson, A.B., Thilsted, S.H., Schwarz, A.M. Food and nutrition security in Solomon Islands. March 25, 2013. Research program on Aquatic Agricultural Systems,


31 Personal communication with WHO (South Pacific Office) indicates that a joint action plan between the ministries responsible for the implementation of the Policy does not exist and monitoring of the

Policy’s progress is not currently taking place

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advertisement; food claims; incidental constitutes; food hygiene; commodity standards; and offences and penalties.32 The Regulations include a mandatory standard for the fortification of wheat flour (iron, folic acid and zinc) and salt (iodine) in Solomon Islands. Amendments to the regulations pertaining food labelling, advertisement and date marking are currently being considered. It was suggested by WHO (Fiji) that sodium could be included in required nutrition content labelling, and that restrictions on marketing food and non-alcoholic beverages to children in line with the WHO recommendation should be considered.33

Draft Asia Pacific Strategy for Emerging Diseases and the International Health Regulations (2005) (APSED-IHR) Implementation Plan 2013-2014: Solomon Islands was granted a two year extension to fulfil the requirements if the APSED-IHR and developed a draft implementation plan in 2013. The plan includes a component on food safety and the implementation of the Pure Food Regulations, 2010.34

In addition, at the 9th meeting of the Ministers of Health for the Pacific Island a declaration was made to commit to providing leadership and whole-of-government responses to tackle the NCD crisis with a focus on the implementation of evidence based initiatives, strengthening health systems and ensuring monitoring and accountability systems are in place with quantified and time bound national targets.

It is, however, not clear whether the above plans, policies and laws are being appropriately implemented or regulated.

5. Proposed interventions to combat malnutrition in Solomon Islands

5.1 Salt Reduction

5.1.1 Health benefits

The Lancet NCD Action Group and the NCD Alliance includes salt reduction as one of five priority interventions in response to the “global crisis in NCDs”, along with tobacco control, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies.35

A 2011 meta-analysis of 17 trials longer than 4 weeks showed that a reduction in salt intake can significantly lower blood pressure in both normotensive and hypertensive individuals, with a dose-response relationship observed between changes in urinary sodium and changes in blood pressure.36

32 Personal communication with WHO South Pacific Office


34 Ibid

35 Beaglehole, Robert, et al. "Priority actions for the non-communicable disease crisis." The Lancet 377.9775 (2011): 1438-1447.

36 He, F. J. Li, J. and MacGregor, G.A. "Effect of longer-term modest salt reduction on blood pressure. Cochrane database of systematic reviews 2013, Issue 4. Art. No.: CD004937. DOI:

10.1002/14651858. CD004937.pub2. collaboration

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As high blood pressure is a direct risk factor for cardiovascular disease and stroke, it has long been assumed that salt reduction must be associated with a reduction in cardiovascular and stroke incidents and deaths. However, the evidence on the impact of dietary salt reduction on the reduction of these outcomes is currently under debate.37

A recent WHO report found that higher salt intake is associated with higher risk of incident stroke, fatal stroke and fatal coronary heart disease. However there was no association between sodium intake and all-cause mortality, incident cardiovascular disease and non-fatal coronary heart disease. The WHO concluded that the strong positive relationship between blood pressure and these outcomes provides indirect evidence that reducing sodium intake can improve these outcomes through a beneficial effect on blood pressure.38

There is minimal evidence for risks associated with reducing salt intake.39

5.1.1 Recommended dietary salt intakes

The proportion of salt derived from processed foods in developing and developed countries is approximately 70-80% with table salt added to foods contributing a minor amount in most countries.40 In 2012 WHO recommended that total daily salt intake for adults be reduced to <2 g/day sodium (i.e., 5g/ day of salt) and for children the maximum recommended intake of 2g/day be adjusted downwards based on the energy requirements of children relative to adults.41

He et al report that recommendations to reduce salt from current levels of 9-12 g/d to 5-6 g/d will have significant effects on reducing blood pressure, but a further reduction to 3g/d will have a much greater effect on blood pressure.42

WHO is developing tools to assist Member States to identify population salt consumption and major sources of sodium in the diet; in the reformulation of a set number of products available on the market; in developing health communication material to assist consumers increase awareness on salt/sodium and to inform consumers on how to read and interpret food labels.43

5.1.2 Cost effectiveness

Cost–benefit analyses have consistently identified reduced sodium intake as one of the most cost-effective public health interventions available.44

In the UK the estimated cost of a strategy involving voluntary reduction in the salt content of processed foods and condiments by manufacturers combined with a sustained mass media campaign to encourage dietary change in households and communities was estimated to cost 37 Bochud, Murielle, et al. "Dietary salt intake and cardiovascular disease: summarizing the evidence." Public Health Reviews 33.2 (2012): 530-552.

38 World Health Organization, Sodium intake for adults and children, 2012: Geneva

39 Institute of Medicine (US) Committee on Strategies to Reduce Sodium Intake. (2010) Strategies to Reduce Sodium Intake in the United States Washington (DC): National Academies Press (US).

40 James, W.P, Ralph, A, Sanchez-Castillo, C.P. The dominance of salt in manufactured food in the sodium intake of affluent societies. Lancet 1987; 1: 426-429

41 WHO, 2012 Guideline: Sodium intake for adults and children.http://www.who.int/nutrition/publications/guidelines/sodium_intake_printversion.pdf

42 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;370:2044–53.

43 WHO, http://www.who.int/dietphysicalactivity/reducingsalt/en/

44 WHO, Sodium intake for adults and children, 2012: Geneva

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http://www.who.int/dietphysicalactivity/reducingsalt/en/

US $0.09 per person per year.45 This was much more cost effective than tobacco control strategies which were estimated to cost US $0.26 per person per year, and resulted in a reduction in average salt intake from 9.5 g/d in 2003/2004 to 8.1 g/d by 2011. This was reported to result in an estimated 6,000 fewer deaths caused by cardiovascular disease per year, thereby saving the national economy, £1.5 billion per year.46

A World Health Organization study showed that sodium reduction, either voluntary or legislated, was more cost effective than traditional hypertension control programs for all but one geographic region (East Africa). Population salt reduction was deemed to be at least cost effective for every region for both legislated and voluntary programs.47

5.1.3 Salt reduction programs: what works?

Several developed countries have implemented population based salt reduction programs (Refer to Appendix 3 for more details). Most salt reduction programs are multi-faceted and include education, regulatory or voluntary measures to reduce salt content in processed foods and voluntary or mandatory labelling. Many programs target a certain sector of the food industry and/ or a specific population group.

The United Kingdom (UK) and Finland are two of the only countries to implement successful multisectorial, comprehensive national campaigns which have successfully incorporated coordinated approaches to target the food industry consumer awareness and food labelling.48,49 Australia intends to take this approach, but up until now little progress has been made 50 (see Appendix 2 for the proposed national approach in Australia).

United Kingdom Salt Reduction Program

Based on the results of three national dietary assessment surveys, the UK Scientific Advisory Committee on Nutrition (SACN) recommended that the public reduce salt intake to an average of 6 g/day (2,400 mg of sodium/day).51 The UK’s Food Service Agency (FSA) made salt reduction a priority.52 FSA created consumer awareness about the large amount of salt in processed foods and the link between salt intake and heart disease; and at the same time influenced the food and restaurant industries to reduce sodium levels in foods by about one-third over five years.53,54


2007;370:2044–53.

46 Department of Health. Assessment of dietary sodium levels among adults (aged 19 - 64) in England, 2011. London: Department of Health; 2012

47 Neal, Bruce, Wu Yangfeng, and Nicole Li. "The effectiveness and costs of population interventions to reduce salt consumption." Background paper prepared for the WHO Forum and Technical Meeting

on Reducing Salt Intake in Populations. 2006


2007;370:2044–53.

49 He, F.J. Campbell,N.R.C. MacGregor,G.A. reducing salt intake to prevent hypertension and cardiovascular disease. Rev Panam Salud Publica. 2012;32(4):293–300.

50 Webster, J. Dunford, E. Huxley, R. Li, N. Nowson, C.A. Neal, B. The development of a national salt reduction strategy for Australia. Asia Pac J Clin Nutr 2009; 18 (3): 303-309

51 Salt and Health (2003). The stationery office, Norwich, UK. Available: http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf

52 Institute of Medicine (US) Committee on strategies to reduce sodium intake. Strategies to reduce sodium intake in the United States. Edited by Henney, J. Taylor, C. L. Boon, C.S. Washington (DC):

National Academies Press (US): 2010 Appendix C International efforts to reduce sodium consumption. http://www.ncbi.nlm.nih.gov/books/NBK50961/

53 Food Standards Agency. Agency publishes 2012 salt reduction targets. London: FSA; 2009. Available from: www.food.gov.uk

54 Consensus Action on Salt and Health. Available from: www.actiononsalt.org.uk/

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http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf

To help consumers reach the 6 g/day target, the UK government undertook a salt reduction program which incorporated 3 main elements, as described in Appendix C on international efforts to reduce sodium consumption prepared by the Institute of Medicine (US) Committee on strategies to reduce sodium intake.

1. Recognising that approximately 75% of salt intake was derived from processed foods, the UK government cooperated with the food industry to voluntarily reduce salt in processed foods. Based on public and stakeholder feedback, 85 processed food categories including bread,55 bacon, breakfast cereals, and cheese were included among the target foods. FSA reported that it aimed to set challenging levels that would have a meaningful impact on consumer salt intake, while being mindful of food safety and technical issues and acknowledging that major processing changes would be necessary for certain foods to meet the targets. The targets have been revised and modified frequently and new targets were set for most foods in 2012.

2. A public awareness campaign was developed to raise the awareness of why a high salt intake is detrimental to health and what the individuals can do to reduce intake. The program included a staged four phase multi-media campaign incorporating messages on the adverse consequences of excessive salt on health, way to achieve a goal of eating less than 6g salt /day, choosing low salt products and checking food labels. These messages were supported by a booklet produced by the British Heart Foundation.

3. Using a traffic light colour labelling system, voluntary nutrition labelling was introduced by supermarkets and manufactures to improve nutrition labelling. Some retailers used front of packaging labelling providing percentage of guideline daily amount (GDA) and others used a traffic light colour system. A green light indicated that a product had ≤ 300 mg sodium per 100 g or 100 mL; a red light indicated that a product had > 1,500 mg per 100 g of sodium or 100 mL and anything between 300 and 1,500 mg sodium per 100 g or 100 mL had an amber light. Others used multiple traffic light systems indicating the amount of various nutrients. A recent impact assessment survey indicated that multiple traffic light colours were preferred for all and that a uniform format including the words high medium and low in addition to the colour and percentage of GDAs were the easiest to understand for all products.

The impact of the program has been a decrease in salt consumption of almost 360mg/day since the program commenced (a decrease from an average of 9.5 g/day to 8.6 g/day of salt, equivalent to a decrease in sodium of 3,800 mg/day to 3,440 mg/day). There is also some evidence to suggest that manufacturers have reformulated products to make their products qualify for a better traffic light profile.56

5.1.4 Critical program areas for salt reduction

55 Brinsden, H.C. Feng, J.H. Jenner, K.H. MacGregor, G.A. Surveys of the salt content in UK bread: progress made and further reductions possible

56 Institute of Medicine (US) Committee on strategies to reduce sodium intake. Strategies to reduce sodium intake in the United States. Edited by Henney, J. Taylor, C. L. Boon, C.S. Washington (DC):

National Academies Press (US): 2010 Appendix C International efforts to reduce sodium consumption. http://www.ncbi.nlm.nih.gov/books/NBK50961/

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http://www.ncbi.nlm.nih.gov/books/NBK50961/

Experience of salt reduction strategies indicates that the following elements need to be in place to develop effective evidence based salt reduction strategy: Commitment from the government and the establishment of a working group tasked to

reduce dietary salt intake (represented by government, consumer groups and the food industry).

Established baseline information on dietary salt intake measured by 24hr urinary sodium and salt in the food supply to establish salt reduction goals.

Established databank of the salt content of available processed foods. Determination of the salt content of different processed foods and their contribution to

overall salt availability. Modelled impact on dietary salt availability with reductions on targeted foods. Current food and nutrient labelling regulations and compliance. Consumer awareness and knowledge of dietary salt and health.

Refer to Appendix 5 for organisations that may be able to assist with salt reduction strategies and programs.

5.1.5 Salt reduction in Pacific Island Countries

Salt reduction is a key priority for NCD prevention and control across the Pacific. Fourteen countries (including Solomon Islands) have developed draft salt reduction strategies. The strategies include baseline assessments, policy interventions, strategic health communication, settings-based interventions and monitoring and surveillance.57 Anecdotal evidence suggests that the implementation of salt reduction actions in Solomon Islands, led by MOH has been delayed because of capacity and resources issues.

World Action on Salt and Heath reports that activities to reduce salt intake have gained momentum in Pacific Island Countries, following a meeting with Ministers at the Pacific Island Food Summit in Vanuatu in 2010. Since this event the South Pacific Office of WHO has supported workshops on the benefits of salt reduction in Fiji, Tonga and Guam.58

The George Institute (based in Sydney, Australia) has been working collaboratively with the WHO to facilitate the development of salt reduction activities as part of NCD strategies in Fiji, Nauru and the Solomon Islands.59 Activities such as limiting the purchase of salt in schools and hospitals, developing food composition databases and standards for salt levels in foods and educating people about low salt cooking are being implemented in the region.60 However, since these activities are still in the early stages of implementation, there is not yet a clear indication of their impact or effectiveness.

In addition, the South Pacific Office of WHO is currently developing regional voluntary targets for salt reduction in selected processed foods. The targets were endorsed in principle at the 5th

57 Personal communication with WHO, South Pacific Office

58 World Action on Salt and Health, http://www.worldactiononsalt.com/worldaction/australia/index.html

59World Action on Salt and Health, Salt Action Summary, http://www.worldactiononsalt.com/worldaction/australia/index.html#sthash.KzVyk6cg.dpuf

60 Ibid

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http://www.worldactiononsalt.com/worldaction/australia/index.html

Pacific NCD Forum in September 2013. Once finalised, the targets will be presented at the upcoming Ministers of Finance and Ministers of Health Meeting in July 2014. Some PICs are considering incorporating the targets into existing food standards, while other countries are considering the development of specific labelling requirements for products exceeding the target and other measures. Solomon Islands has not yet decided on an approach on how best to incorporate the targets. Additional support will be required to assist the GoSI to undertake this process.61

5.1.6 Recommendations for reducing salt intake in the Solomon Islands

The following recommendations are based on the premise that: strategies to reduce salt consumption are required in Solomon Islands; salt reduction strategies are cost effective; salt reduction is a priority area for the government of Solomon Islands; and that additional support is required to implement these recommendations.

1. Solomon Islands should adopt the Pacific regional salt reduction targets, developed by WHO in order to develop regulatory measures for the reduction of salt in processed foods in the country. This could be in the form of standards, product and shelf labelling, taxation (where sodium content is above standard), etc. Further support is required to assist the government in this process.

2. A three pronged strategy could be considered by GoSI to reduce salt intake including; i) a public education and awareness campaign on the benefits of reducing salt intake; ii) co-operation with the food industry to reduce salt content in targeted processed foods; and iii) voluntary (as in the UK) or mandatory (as in Finland) salt labelling.

3. Given the resource and capacity limitations in Solomon Islands, a single product reduction in salt (e.g., bread62 or tuna) could be considered as a starting point rather than tackling multiple food categories. Staged salt reduction in bread has been successfully implemented in New Zealand with no technical and safety issues and with no reduction in consumer demand for salt reduced bread products.63 64 Additional information is required to determine whether processed local tuna production has picked up since the disruption to production in the early 2000s, to clarify whether it may be a potential food to target for salt reduction. Other than tuna, there is a large manufacturer in Solomon Islands producing bread and biscuits; this may be an alternative or additional avenue for targeted food based salt reduction.

5.2 Food Fortification


62 Dunford, E.K. Eyles, H. Ni Mhurchu, C. Webster, J.L. and Neal, B.C. Changes in the sodium content of bread in Australia and New Zealand between 2007 and 2010: implications for policy. MJA 2011;

195: 346-349 doi: 10. 5694/mja11.10673

63 Brinsden H.C, He F.J., Jenner, K.H., MacGregor, G.A. Surveys of the salt content in UK bread: progress made and further reductions possible. BMJ Open 2013; 3:e002936. doi:10.1136/bmjopen-2013-

002936

64 Dunford, E.K., Eyles,H., Ni Mhurchu, C., Wenster, J.L., Neal, B.C. Changes in the sodium content of bread in Australia and New Zealand between 2007 and 2010: implications for policy. MJA 195 (6)

19 September 2011.

13

While consuming a varied and balanced diet consisting of adequate levels of all vitamins and minerals is the optimal way to achieve good health and nutrition, this is not a realistic option for much of the world’s population. Fortified food can provide a steady supply of all the required micronutrients to entire populations without having to wait for long term changes in food habits or dietary behaviour. The process of fortification generally takes place during food processing by the food industry at a central level and requires no active participation of end users. It does not require change in dietary habits or behaviour and results in little or no change in the texture or taste of the vehicle.

Where appropriate levels of absorbable micronutrients are used in the most appropriate food vehicles, food fortification programs can successfully contribute to the reduction of micronutrient deficiencies. One of the most commonly fortified vehicles is salt. Salt has been used as a vehicle for iodine supplementation since the 18th century and during the last two decades governments around the world (over 180 countries) have adopted universal salt iodization to virtually eliminate iodine deficiency.65

According to WHO classifications, the prevalence of anaemia in non- pregnant women and children aged 6-59 months is a ‘severe’ public health issue in Solomon Islands (See section 4 in this report). This is a public health challenge requiring multi sectorial, integrated, comprehensive programmatic approaches, and food fortification should be considered to be one of several potential strategies. Fortifying food with iron has been identified as one of the most cost-effective ways to address malnutrition.66

Two common food vehicles for iron fortification in developed and developing countries are flour and rice (refer to Appendix 4 for the status of fortification programs in PICs). The Food Fortification Initiative states that when appropriate levels of easily absorbed iron are used and vulnerable populations consumes fortified products daily, fortification can impact iron status within 12 months of implementation. As it takes time for programs to become fully operational, it is estimated that the impact on the nutritional iron status may take up to three years after the inception of the program.67

5.2.1 Flour/ wheat fortification

Flour has been used as a vehicle for vitamin and mineral fortification for nearly a century and has been very successful in contributing to the reduction of vitamin and mineral deficiencies in many countries.68 Fortifying flour with iron has been shown to improve iron status among specific populations in at least four countries including China, Iran, Venezuela and Fiji. However, iron status of the population is rarely measured before and after fortification, making it difficult to report results.69 Eight sub-national studies have found that fortifying flour with folic

65 Food Secure Pacific, Rice Fortification FAQs: http://foodsecurepacific.org/wp-content/uploads/2013/01/FAQs_Final.pdf

66 Copenhagen Consensus 2008: http://www.copenhagenconsensus.com/sites/default/files/CC08_results_FINAL_0.pdf

67 Flour Fortification Initiative, FAQ about Nutrition: http://ffinetwork.org/about/faq/faq_nutrition.html, (cited October 2013)


69 Flour fortification Initiative, FAQ about Nutrition : http://ffinetwork.org/about/faq/faq_nutrition.html, (cited October 2013)

14

http://ffinetwork.org/about/faq/faq_nutrition.html

http://foodsecurepacific.org/wp-content/uploads/2013/01/FAQs_Final.pdf

http://ffinetwork.org/about/faq/faq_nutrition.html


acid reduced the incidence of neural tube birth defects such as spina bifida by between 31% and 78%.70

Currently over 30% of the world’s wheat flour produced in large mills is fortified with iron and/or folic acid and over 60 countries have legislative requirements and standards requiring all flour produced in large mills be fortified.71 WHO recommends the individual or combined addition of iron, vitamin A, folic acid, zinc and vitamin B12 to wheat and maize flours. Technical issues such as appropriate nutrient levels to add, its interactions with the food and other nutrients, the type of flour or the consumer acceptability are important to consider prior to the initiation of a fortification program.72 The WHO/FAO guidelines for the fortification of wheat flour are available at: http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf.

According to the FAO Solomon Islands imported 11,709 metric tons of wheat grain and 203 metric tons of flour in 2009.73 Solomon Islands already has a flour fortification program in place. The program of flour fortification (with iron, zinc and folate) in Solomon Islands commenced in 2011, following the endorsement of the Pure Food Regulations in 2010.74 However, anecdotal evidence indicates that there is a general lack of awareness and understanding of the mandatory standards for both wheat flour and salt fortification. It was also reported that the standards are poorly enforced.75

5.2.2 Rice fortification

Rice is the main staple food of approximately half of the world’s population.76 In 2009 Solomon Islands produced 4,434 metric tons of rice and imported 10,828 tons,77 and per capita consumption of rice more than doubled between 1990 and 2003.

Food Secure Pacific reports that several studies have demonstrated that the regular consumption of rice fortified with adequate levels of bio-available forms of micronutrients results in a significant reduction in the prevalence of micronutrient deficiencies.78

Fortified rice is available in Brazil, China, Columbia, Costa Rica, Nicaragua, Papua New Guinea (PNG), the Philippines and the United States.79 While Brazil, Colombia, Indonesia, the Dominican Republic, and the United States have large-scale rice fortification programs, only five countries in the world have mandatory rice fortification:80 PNG, Costa Rica, the Philippines, Nicaragua and Panama81. All rice in PNG is said to be fortified, following the issuing of a Food

70 Ibid; Blencowe H, Cousens S, Modell B, Lawn J, Folic acid to reduce neonatal mortality from neural tube disorders. Int. J. Epidemiol. (2010) 39 Suppl 1, i110-121


72 World Health Organisation, e-Library of Evidence for Nutrition Actions (eLENA), Fortification of wheat and maize flours

73 Flour Fortification Initiative , Country Profile – Solomon Islands : http://ffinetwork.org/country_profiles/country.php?record=25, (cited October 2013)

74 Personal communication with WHO, South Pacific Office

75 Personal communication with WHO, Solomon Islands Office

76 World Health Organisation, e-Library of Evidence for Nutrition Actions (eLENA), Fortification of rice

77 Flour Fortification Initiative, Country Profile- Solomon Islands: http://ffinetwork.org/country_profiles/country.php?record=25, (cited October 2013)


79 Rice Resource Group, FAQS : http://riforg.gainhealth.org/sites/riforg.gainhealth.org/files/RiFoRG_FAQs_Jan%202011.pdf

80 Ibid.

81 Flour Fortification Initiative, Country Profiles : http://ffinetwork.org/country_profiles/index.php, (Cited October 2013)

15

http://ffinetwork.org/country_profiles/index.php


http://ffinetwork.org/country_profiles/country.php?record=25

http://ffinetwork.org/country_profiles/country.php?record=25


http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fort.pdf

Sanitation Regulation that mandates the addition of iron, thiamin and niacin to rice,82 but it is unclear how consistently the requirement is being implemented and regulated.

Currently, technologies exist for rice to be fortified with iron, zinc, calcium, vitamin A, folic acid, thiamin, niacin and vitamin B12.83 Rice can be fortified easily by adding micronutrient powders that adhere to the grains or spraying the rice grains to form a protective coating.84 Extruding and shaping rice into partially precooked grain like structures using a premix and blending these with natural polished rice is also a method of fortification, however the retention of the added micronutrients during washing and cooking remains unknown.85 According to the FFI, the retail cost of rice may increase 1-4% depending on the fortification method used,86 but the Rice Resource Group highlights that the incremental increase in retail cost is negligible (between 8 and 16 US cents per 10kg of rice), and that the cost-benefit ratios are positive.87

WHO recommends further research in this area to develop the evidence-base on the use of fortified rice and to develop global guidelines for the fortification of rice.88

5.2.3 Critical program elements for food fortification

Experience with staple food fortification (salt, wheat flour, maize flour and oil) has shown that the most successful national scale programs, with high population consumption have all be associated with an enforceable food standard requirement for fortification.89

To facilitate fortified foods reaching the whole population, national fortification requirements should be considered. This is especially feasible in countries where most of the fortified food is imported through a few external traders or in countries that grow the food being fortified and where fortification can be routed through a few centralized mills.90

Refer to Appendix 5 for organisations that may be able to assist with more information on food fortification strategies and programs.

5.2.4 Recommendations for food fortification in the Solomon Islands Review the flour fortification program in Solomon Islands – is it enforced, what is the quality,

reach, consumption, is it working, and does it need strengthening?



84 World Health Organisation, e-Library of Evidence for Nutrition Actions (eLENA), Fortification of rice

85 Rice Fortification in Developing Countries: A Critical Review of the Technical and Economic Feasibility. A2Z Project, Washington, DC, April 2008.

86 Flour Fortification Initiative, FAQs : http://www.ffinetwork.org/about/faq/faq_consumers.html


88 WHO http://www.who.int/elena/titles/rice_fortification/en/



16




http://www.ffinetwork.org/about/faq/faq_consumers.html

Determine the extent to which flour and rice are consumed by populations at risk of micronutrient deficiencies in the Solomon Islands

Assess anaemia/iron deficiency anaemia status. The most recent data is from the 2006 – 07 DHS

Complete the above steps before deciding whether rice fortification is required in Solomon Islands

Review experiences and results from neighbouring countries – e.g. PNG, Fiji Explore potential support from GAIN and/or Micronutrient Imitative (MI) for technical and

operational support for food fortification

6. Recommendations for addressing malnutrition in Solomon Islands

Improve base-line data for nutrition indicators, in particular:- Prevalence of anaemia in vulnerable groups (women of reproductive age,

adolescents, pregnant women and children under 5 years)- intake of rice and flour/bread of these groups- Salt content of commonly consumed foods

Review bottlenecks in the flour fortification processes. Consider requesting the assistance of the Flour Fortification Initiative or GAIN

Adopt the Pacific regional salt reduction targets, developed by WHO in order to develop regulatory measures for the reduction of salt in processed foods in the country. This could be in the form of standards, product and shelf labelling, taxation (where sodium content is above standard), etc.

Consider bread as a medium for salt reduction and fortification Review food labelling regulations and systems for monitoring compliance

17

Appendix 1 Nutrition and Health profile - Solomon Islands

GeneralMaternal mortality rate (deaths per 100,000 live births)reported1 150Maternal mortality ratio ( deaths per 100,000 live births) adjusted2 93 (2010)Under five mortality rate(U5MR) (deaths per 1,000 live births)3 22 (2011)Infant mortality rate (deaths per 1,000 live births)4 18 (2011)Neonatal mortality rate (deaths per 1,000 live births)5 12 (2011)Prevalence of low birth weight (less than 2,500g)6 13%Infant and young child feeding practicesInitiation of breastfeeding within the first hour of birth7 75%Percentage of infants under six months who are exclusively breastfed8 74%Median duration for exclusive breastfeeding (months)9 5.1Percentage of infants for whom semi-soft food is introduced at 6-8 months10 81%*Percentage of children who are breastfed at age 20-23 months11 67%Growth*Prevalence of underweight (moderate and severe) (WAZ<-2) in children aged 0- 59 months12 11.8%Prevalence of severe underweight (WAZ<-3) in children aged 0- 59 months13 2.4%Prevalence of wasting (moderate and severe) (WHZ<-2)in children aged 0-59 months14 4.3%Prevalence of severe wasting (WHZ<-3) in children aged 0-59 months15 1.4%Prevalence of stunting (moderate and severe) (HAZ<-2) in children aged 0-59 months16 32.8%a

Prevalence of severe stunting (HAZ<-3) in children aged 0-59 months17 8.5%Prevalence of overweight (BAZ>+2 ) in children aged 0-59 months NAPrevalence of overweight (WHZ>+2) in children aged 0-59 months18 2.5%Prevalence of underweight or “thinness” (BMI < 18.5) in adolescent girls aged 15 – 19.9 years19

2.4%

Prevalence of overweight (BMI 25-29.9) in adolescent girls aged 15 – 19.9 years20 26.3%Prevalence of obesity (BMI ≥30) in adolescent girls aged 15 – 19.9 years21 2.6%Prevalence of underweight or ”thinness” (BMI < 18.5) in non-pregnant women aged 15 – 49 years22

1.9%

Prevalence of short stature (<145cm) in non-pregnant women aged 15-49 years23 3.0%Prevalence of overweight (BMI 25 – 29.9) in non-pregnant women aged 15 – 49 years24 29.9%Prevalence of obesity (BMI ≥30) in non-pregnant women aged 15 – 49 years25 14.5%Prevalence of underweight (BMI<18.5) in men aged 15-49 years26 2.2%Prevalence of overweight (BMI25 -29.9) in men aged 15-49 years27 25%Prevalence of obesity (BMI≥30) in men aged 15-49 years28 5.8%Prevalence of overweight(BMI>25) all adults29 65.2%Prevalence of obesity (BMI >30) in all adults30 30%MicronutrientsPrevalence of any anaemia(Hb<11.0 g/dl)in children aged 6-59 months 48.5%b

18

Prevalence of mild anaemia (Hb 10.0-10.9 g/dl) in children aged 6-59 months31 29%Prevalence of moderate anaemia (Hb 7.0-9.9 g/dl) in children aged 6-59 months32 18.6%Prevalence of severe anaemia (Hb <7.0 g/dl) in children aged 6-59 months33 0.5%Percentage of children under five years who consumed iron rich foods in the 24 hours prior to the 2007 DHS survey34

31%

Prevalence of anaemia (Hb<12.0g/dl) in adolescent girls aged 15 – 19 years35 35.5%Prevalence of anaemia (Hb<12.0g/dl) in non-pregnant women aged 15-49 years36 44.3% bPrevalence of mild anaemia (Hb 10.0-11.9 g/dl) in non-pregnant women aged 15-49 years 37 36%Prevalence of moderate anaemia (Hb 7.0-9.9g/dl) in non-pregnant women aged 15-49 years 38

7.6%

Prevalence of severe anaemia (Hb <7.0g/dl) in non-pregnant women aged 15-49 years 39 0.6%Prevalence of anaemia (Hb <11.0g/dl) in pregnant women40 60.1% bPercentage of pregnant women who took iron supplementation for < 60 days during pregnancy41

26.2%

Percentage of pregnant women who took iron supplementation for > 90 days during pregnancy42

19.4%

Prevalence of Vitamin A Deficiency (VAD) (retinol binding protein< 0.7µmol/L) in children aged 6 – 59 months

NA

Prevalence of VAD in preschool children (xerophthalmia) 43 1.55%Prevalence of VAD (retinol binding protein < 0.7µmol/L) in non-pregnant women aged 15 – 49 years

NA

Prevalence of VAD in pregnant women (self-reported night blindness) NAPercentage of children aged 6-35 months who consumed vitamin A rich foods in the 24 hours prior to the 2007 DHS survey44

90.6%

Percentage of women who consumed vitamin A rich foods in the 24 hours prior to the 2007 DHS survey 45

92.0%

Percentage of children aged 6-59 months reached with 2 doses of vitamin A supplements NAPercentage of children aged 6-59 months who received VAS in the 6 months prior to the 2007 DHS survey46

7.4%

Percentage of households consuming adequately iodized salt (15 parts /million or more) NANon communicable diseases and risk factors associated with NCDsRaised blood pressure in adults aged over 25years ( the percentage of the population aged over 25 years having a systolic blood pressure≥140mmHg and or a diastolic blood pressure ≥90 Hg or on medications to lower blood pressure)47

30.8%

Raised blood pressure in women aged over 25 years( as above)48 28.9%Raised blood pressure in men aged over 25years(as above))49 32.7%Raised blood glucose in adults aged over 25 years(the percentage of the population aged over 25 years with a fasting plasma glucose value≥7.0mmol/L (126mg/dl) or on medication for raised blood glucose50

14.9%

Raised blood glucose in women aged over 25 years (as above)51 15.4%Raised blood glucose in men aged over 25 years(as above)52 14.3%Raised cholesterol in adults aged over 25 years (the percentage of the population aged over 25 years having a total cholesterol level≥5.0mmol/L(190mg/dl)53

32.4%

19

Raised cholesterol in women aged over 25 years (as above)54 35.4%Raised cholesterol in men over 25 years (as above) 29.5%Daily tobacco smoking in adults aged over 15 years( the percentage of the population aged over 15 years who smoke tobacco on a daily basis)55

28.8%

Daily tobacco smoking in women aged over 15 years (as above)t 14.4%Daily tobacco smoking in men aged over 15 years (as above)56 42.4%Physical inactivity in adults aged over 15 years (the percentage of the population aged over 15 years who engage in less than 30 minutes of moderate activity five times per week or less than 3 times 20 minutes of vigorous activity per week or equivalent57)

42.6%

Physical inactivity in women aged over 15 years (as above)58 48.6%Physical inactivity in men aged (as above)59 36.8%

a Classified as a” High prevalence” according to WHO cut off values for public health significanceb Classified as a ”severe public health problem according to WHO cut off values for public health significance(2008)*Reported against the 2006 World Health Organisation (WHO) Growth Standards **Data differs from standard definition or refers to only part of the country

20

Appendix 2 Key elements of the salt reduction strategy proposed for Australia91


21

MONITORING AND EVALUATION1. Establish a database to document details of packaged foods2. Report changes in the average salt content of foods by category, manufacturer

and retailer on an annual basis

GOVERNMENT STRATEGYGovernment to make salt reduction a priority as part of national health programDeliver a national education program about salt

LABELLING STRATEGY Implementation of an evidence-based, front of pack labeling scheme

MEDIA & COMMUNICATIONSSTRATEGY 1. Surveys of awareness about salt 2.Website3. Consumer education materials- Print, radio and TV coverage

FOOD INDUSTRY STRATEGY

1. Series of consultative meetings with industry

2. Securing agreement on targets for salt levels in different food categories

3. Development of individual company plans

PROMOTE CLEAR LABELLING SO SALT CONTENT IS IMMEDIATELY APPARENT

INCREASE POPULATION KNOWLEDGE OF BENEFITS OF A LOW SALT DIET

25% REDUCTION IN SALT CONTENT OF PROCESSED AND CATERED FOODS

Appendix 3 Population level salt reduction strategies, by country

Country/ organisation

Recommended salt intake

Target population

Time frame Strategy Outcome

National Institute for Health and Clinical Excellence (UK)

3 g/d Whole population

By 2025 Reformulation – setting salt reduction targets for different product categories and encouraging the food industry to make reductions.

Advocating for voluntary front of pack labeling to identify high, medium and low salt foods as part of the “traffic light” labeling scheme.

Started in 2003 and launched consumer program in 2005. By 2008 demonstrated a 0.9g reduction (from 9.5g to 8.6 g/d)

Consumer demand for lower salt products has increased

Finland92,93,94 Commenced in 1975 ReformulationFood industry substituting sodium chloride with Pansalt, a potassium and magnesium enriched form of salt

Compulsory warning signs on high salt foods

In 1993, salt-labeling legislation was implemented by the Ministry of Trade and Industry and the Ministry of Social Affairs and Health for food categories that contribute high amounts of sodium to the diet, such as manufactured food items and meals, requiring that such foods be labeled with the percentage of “salt (NaCl) by fresh weight of the product” (Pietinen et al., 2007). The legislation also requires a “high salt

By 2002 had demonstrated a 3 g/d reduction (from 12 to 9 g/d).

92 Pietinen, P. Valsta, L.M. Hirvonen, T. and Sinkko, H. labelling the salt content in foods: a useful tool in reducing sodium intake in Finland. Public Health Nutrition. March 2007: 1-6 DOI: 10.1017/SI368980007000249

93 World Action on Salt & Health. Finalnd: Salt action summary. Available: http://www.worldactiononsalt.com/worldaction/europe/53774.html (Accessed8/11/2013)

94 Laatikainen, T. Pietinen, P. Valsta, L. Sundvall, J. Reinivuo, H. and Tuomilehto, J. Sodium in the Finnish diet: 20-year trends in urinary sodium excretion among the adult population. European Journal of Clinical Nutrition (2006) 60: 965-970

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http://www.worldactiononsalt.com/worldaction/europe/53774.html

content” label on foods that contain high levels of sodium and allows foods low in sodium to carry a “low salt” label (see Table C-1). Other labels in use include the Pansalt logo (used on products with sodium-reduced, potassium- and magnesium-enriched mineral salts) and the “Better Choice” label that was put in use by the Finnish Heart Association in 2000 (He and MacGregor, 2009; Karppanen and Mervaala, 2006).

Australia95 UL of 6 g/dDietary intake target of 4 g/d

A multi-faceted 3-pronged strategy similar to the UK approach but adapted to the Australian context. Specific objectives are to:achieve an average 25% reduction in the salt content of processed and catered foods), to increase population knowledge of the benefits of low salt diets and to promote clear labeling of foods so that the salt content is immediately apparent.

Has not achieved significant population level reductionsRecommendation (NHMRC) for food industry to reduce salt in foods.NHF has implemented a tick program leading a number of companies to reduce salt content of some products

US96 <6g/d Adults

4 g/d African Americans, adults >=51 yrs, those with hypertension, diabetes or chronic kidney


96 Institute of Medicine (US) Committee on strategies to reduce sodium intake. Strategies to reduce sodium intake in the United States. Edited by Henney, J. Taylor, C. L. Boon, C.S. Washington (DC): National Academies Press (US): 2010

23

diseaseCanada97 2004 – dietary survey

reporting on dietary salt intake2006 – Chair in hypertension prevention and control appointed to lobby government for salt reduction measures2007 – working group (representing government, consumer groups and food industry representatives) established by the government with the task of developing a salt reduction strategy.Three-pronged approach (education, voluntary reduction of sodium levels [in processed foods and foods sold by foodservice operations], and research). Stages – i) gather baseline data on salt intake ii) gathering data on education efforts; & voluntary efforts to reduce sodium in foods; (3) consumers’ perspectives on sodium and its relation to hypertension; (4) sodium, taste, and food choices; (5) functional uses of sodium; and (6) regulatory barriers or disincentives to reduce sodium in foods. Final stage was to set goals and develop action plans and time lines for implementation and monitoring.

97 World Action on Salt and Health. Salt Action Summary: Canada. January 2013, http://www.worldactiononsalt.com/worldaction/northamerica/53674.html

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Appendix 4 Fortification legislation status of countries in the Pacific Country Wheat Flour Maize flour RiceAmerican SamoaAustralia Mandatory -- --Christmas Island -- -- --Cocos (Keeling) Islands -- -- --Cook Islands Planning -- --Fiji Mandatory -- --French Polynesia -- -- --Guam -- -- --Kiribati -- -- --Marshall Islands Planning -- --Micronesia, Federated States of -- -- --Nauru Planning -- --New Caledonia -- -- --New Zealand No Fortification -- --Niue Planning -- --Norfolk Island -- -- --Northern Mariana Islands -- -- --Palau -- -- --Papua New Guinea -- -- MandatoryPitcairn Islands -- -- --Samoa -- -- --Solomon Islands Mandatory -- --Tokelau -- -- --Tonga -- -- --Tuvalu Planning -- --Vanuatu Planning -- --Wake Island -- -- --Wallis and Futuna Islands -- -- --

Source: Food Fortification Initiative, Pacific Profile: http://ffinetwork.org/regional_activity/pacific.php, (Cited October 2013)

DefinitionsMandatory: Country has legislation that has the effect of mandating fortification of one or more types of wheat or maize flour or rice with at least iron or folic acid.Planning: There is written evidence that the country's government is acting to prepare, draft, and/or move legislation for mandatory fortification.Voluntary: This category is used if at least 50 % of the industrially-milled wheat or maize flour or rice produced in the country is being fortified through voluntary efforts.Dashes in the table below indicate that no information is available.

25

http://ffinetwork.org/regional_activity/pacific.php

Appendix 5 Organisations that can support the implementation of food fortification and salt reduction strategies and programs

1. Food Fortification1.1 Global Alliance for Improved Nutrition (GAIN)

http://www.gainhealth.org/The Global Alliance for Improved Nutrition (GAIN) was created in 2002 at a Special Session of the UN General Assembly on Children. GAIN is a Swiss foundation with the headquarters in Geneva with a special international status granted by the Swiss government. GAIN has country offices in Abuja, Accra, Addis Ababa, Dhaka, Kabul, Jakarta, Nairobi, and New Delhi. It also has representative offices in Amsterdam, London, Singapore and Washington D.C. GAIN supports public-private partnerships to increase access to the missing nutrients in diets necessary for people, communities and economies to be stronger and healthier. Over the past decade GAIN has scaled up operations by working in partnership with governments and international agencies, and through projects involving more than 600 companies and civil society organisations in more than 30 countries, reaching an estimated 667 million people .About half of the beneficiaries are women and children. GAIN’s goal is to reach 1 billion people by 2015 GAIN provides support to 30 countries and does not operate in PICS. Personal communication with the Asian regional manager of GAIN indicates that GAIN would require external funding to provide support to countries in the PacificGAIN's National Fortification Program began in 2003, has expanded to support 19 countries with high levels of vitamin and mineral deficiencies. Projects fortify foods and condiments including wheat and maize flour, sugar, vegetable oil, milk, soy sauce and fish sauce. Vitamins and minerals used to fortify foods include Vitamin A, Vitamin D, iron, zinc, folic acid (B9), thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6) and cobalamin (B12).A broad coalition of governments, businesses, international organizations and civil society partners, known as National Fortification Alliances, support GAIN's projects. GAIN funds work on policy, legislation and regulation, the purchase of premix and fortification equipment, consumer awareness campaigns around fortification and training in fortification techniques and quality assurance for government officials and staff in mills, refineries and plants. Projects are sustainable as fortification continues after a grant agreement ends.GAIN’s projects have delivered results. In South Africa, neural tube defects fell by 30 percent after folic acid was added to maize meal and wheat flour. In China, data collected from 21 health clinics showed that anaemia dropped by approximately one third following the fortification of soy sauce with iron.GAIN have a universal salt partnership project with UNICEF to develop new models to reach hard to reach populations and increase coverage in 13 countries with the lowest coverage of iodized salt and the greatest burden of iodine deficiency including Bangladesh, China, Egypt, Ethiopia, Ghana, India, Indonesia, Niger, Pakistan, Philippines, Russia, Senegal and UkraineThe project aims to reach 90 percent of the population in these nations with iodized salt. This represents more than 790 million people not yet covered by worldwide salt iodization programs, including more than 19 million newborn infants every year. Through the seven-year project, GAIN focuses on the supply side of the salt market and will support small- and large-scale salt producers to move to quality iodized salt production that adheres to standards and government

26

http://www.gainhealth.org/programs/gain-national-fortification-program/national-fortification-alliances

http://www.gainhealth.org/

regulations and links to distribution networks. GAIN is also responsible for strengthening the capacity to implement robust public health Monitoring & Evaluation to track progress towards USI and verify the elimination of iodine deficiency disorders (IDD).

1.2 Micronutrient Initiative (MI)http://www.micronutrient.org/english/view.asp?x=1

MI is an independent, not-for-profit organization, based in Ottawa Canada committed to promoting simple cost-effective solutions for hidden hunger and developing innovative new solutions where needed. MI works in partnership with governments, the private sector, UN agencies and civil society organizations to:

Help governments, food producers, and partner organizations develop, implement, and monitor innovative, culturally appropriate and cost-effective programs to get essential vitamins and minerals to the people who need them most

provide technical and financial assistance; offer procurement and quality control services for highly specialized supplies and

equipment needed to prevent hidden hunger; advocate for micronutrient programs; and educate government bodies around the world so that they understand the high benefits that

come from policies, legislation, and programs to ensure the sustained delivery of essential vitamins and minerals

MI focuses on strengthening and integrating delivery platforms for micronutrients and other health interventions; advising governments on how to use their own resources to finance the marginal costs related to adding micronutrient supplementation, including vitamin A, iron and folic acid to existing health services and programs.

1.3 Flour Fortification Initiative (FFI)http://www.ffinetwork.org/ The Flour Fortification Initiative (FFI) is an international partnership of individuals and organizations advocating for and supporting fortification of industrially milled cereal grains. Key partners include government officials, industry leaders, civic sector advocates, and staff of non-governmental organizations. FFI undertakes the following activities Offers guidance to plan fortification programs and conduct industry assessments; Provides training on milling, food control, and regulatory staff on quality assurance and

control; Encourages collaboration to prevent duplication of efforts and identify gaps where work is

needed; Tracks global progress by maintaining country profiles and a global database; Conducts country visits with partners to advocate for adoption of flour fortification

programs; Facilitates creation of national fortification alliances to lead in-country efforts; Advises on the creation, implementation and follow-up of monitoring and evaluation plans

for national fortification programs.

1.4 Rice Fortification Resource Grouphttp://riforg.gainhealth.org/rice-fortification

27

http://www.micronutrient.org/english/view.asp?x=1

The Rice Fortification Resource Group is a global network of partners from governments and international agencies, rice industries, educational, consumer and civic organizations that has a mandate to expand rice fortification globally.The Rice Fortification Resource Group serves to: Promote collaboration of public-private sectors in the advancement of nationally mandated

rice fortification; Provide technical, advocacy and regulatory expertise to nations adopting fortification of rice;

and Engage all appropriate channels of rice production, trade and consumption in all nations as

they move towards rice fortification.

2. Salt reduction2.1 The George Institute

http://www.georgeinstitute.org.au/projects/cost-effectiveness-of-salt-reduction-interventions-in-pacific-islandsThe George Institute, based in Sydney, Australia has received funding through the Australian National Health and Medical Research Council to assess the cost effectiveness of salt reduction strategies in the Pacific Islands. This project is mainly working with Samoa and Fiji. The aim of the NHMRC funded project is to assess baseline population sodium intakes, identify potential multi-sectoral interventions to reduce population sodium intakes and determine the impact of those interventions. These findings will be used to inform national salt reduction strategies. Below is a summary report of a meeting held in the Solomon Islands in 2010 to scope a salt reduction strategy as part of the World Action on Salt and Health (WASH). http://www.worldactiononsalt.com/worldaction/australia/index.htm

A summary of the report (prepared by The George Institute) from the Solomon Islands workshop facilitated by The George Institute and WHO is as follows:

Stepping up action on Salt in the Solomon Islands4th November 2010Venue: Star Event. Solomon Islands.Summary Meeting report1. People in the Solomon Islands are eating too much salt which is bad for their health. To

address this, on Thursday 4th November, the Ministry for Health convened a meeting in Honiara with relevant government departments, consumer organisations, and national and international experts, to discuss and agree immediate actions that could be taken as part of a coordinated effort to reduce salt intakes in the Solomon Islands. The meeting was facilitated by Dr Temo Waqanivalu from the World Health Organisation South Pacific Office and Jacqui Webster from the George Institute for Global Health in Sydney.

2. The urgency of taking action to reverse the increase in Non-Communicable Diseases was highlighted. Diet is one of the major risk factors for NCDs and within this salt is one of the leading causes of high blood pressure which in turn is a key contributor to cardiovascular disease and stroke. Salt reduction was highlighted as one of the most cost effective ways of reducing NCDs with the potential to have a large impact at 1-2% of the cost of clinical hypertension programs. Examples of countries that had already successfully reduced salt

28

http://www.worldactiononsalt.com/worldaction/australia/index.htm

http://www.georgeinstitute.org.au/projects/cost-effectiveness-of-salt-reduction-interventions-in-pacific-islands

http://www.georgeinstitute.org.au/projects/cost-effectiveness-of-salt-reduction-interventions-in-pacific-islands

consumption were discussed and consideration given to the potential for adapting some of the approaches taken to the situation in the Solomon Islands.

3. There was consensus that the Solomon Islands should take immediate action to address salt intakes and in particular to ensure that they did not get worse as a result of increasing imports. The main sources of salt in the diet were identified as salt and sauces added during cooking or at the table, bread, salt fish, tinned fish and meat, canned vegetables, crisps and salty snacks, biscuits and noodles. An initial assessment of the sodium content of foods demonstrated scope for reductions in salt levels.

4. It was agreed that the following actions would be taken: Advocacy work to make political priority (including as part of national diabetes week

w/c 8th November) Completion of collection of sodium composition data to establish a baseline of salt

levels in foods Early consultation with the food industry to raise awareness of the fact that salt is bad

for health and the need for companies to reduce salt in food products Development of a comprehensive strategy with clear objectives to achieve by 2015 and

longer term goals to be achieved by 2020 including the introduction of mandatory targets for salt levels in foods and behaviour change programs linked to activities to increase fruit and vegetable intakes

Activities as part of Salt Awareness Week 17-24 March 2011 Development of proposals for provincial initiatives on salt linked to broader NCD

activities for Healthy Islands Recognition program which will be announced at the Healthy Island Forum in July 2011

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1 UNICEF The State of the World’s Children 2013: Children with Disabilities ( accessed November 5 2013)

http://www.unicef.org/mena/MENA_SOWC_Report_2013_ENG(1).pdf

2 ibid

3 ibid

4 ibid

5 ibid

6 ibid

7 ibid

8 ibid

9 Solomon Islands Demographic and Health Survey 2007

10 UNICEF The State of the World’s Children 2013: Children with Disabilities ( accessed November 5 2013)


11 ibid


13 ibid

14 ibid

15 ibid

16 ibid

17 ibid

18 ibid

19 ibid

20 ibid

21 ibid

22 ibid

23 ibid

24 ibid

25 ibid

26 ibid

27 ibid

28 ibid

29World Health Organization Western Pacific Region. Noncommunicable Diseases in the Western Pacific Region: A Profile: 2012

30 ibid


32 ibid

33 ibid

34 ibid

35 ibid

36 ibid

37 ibid

38 ibid

39 ibid

40 ibid

41 ibid

42 ibid

43Schaumberg DA, Linehan M, Hawley G, O'Connor J, Dreyfuss M, Semba RD, Vitamin A deficiency in the South Pacific.Public Health. 1995 Sep;109(5):311-7


45 ibid

46 ibid

47 World Health Organization Western Pacific Region. Noncommunicable Diseases in the Western Pacific Region: A Profile: 2012

48 ibid

49 ibid

50 ibid

51 ibid

52 ibid

53 ibid

54 ibid

55 ibid



56 ibid

57 ibid

58 ibid

59 ibid