Two Initiatives Worth Their Salt: Reducing Sodium Intake in Philadelphia and Shandong, China

Background information

CDC’s 2013 Vital Signs publication reported that more than 200,000 deaths among Americans younger than age 75 are preventable. These deaths from heart disease and stroke, both primary contributors to cardiovascular disease (CVD), could be prevented through better lifestyle practices and better care. Heart disease and stroke are two of our nation’s leading causes of death, responsible for nearly 1 in 3 deaths in the US each year. Globally, hypertension accounts for almost one-half of heart attacks and strokes. In China alone, CVD caused an estimated 3.5 million deaths in 2008.

Excess sodium intake is a key risk factor for hypertension, and reducing sodium intake is a global and domestic public health priority. A 2007 study found that reducing average population sodium intake by 15% in 23 low- and middle-income countries (bearing 80% of the chronic disease burden) could prevent 8.5 million deaths over 10 years, at a cost of only $0.05 / person / year (see footnote #1). In China and in the US, average sodium consumption is in excess of recommendations (see footnote #2). Primary sources of sodium vary depending on the country: the primary sources of sodium in the US are packaged and restaurants foods, while in China it is salt added during cooking. Thus, efforts to reduce sodium consumption in each country focus on their respective primary contributors to sodium intake.

Shandong Province is the third most populous province in China with 96 million residents. Rates of hypertension and salt intake in adults are higher than the national average; Shandong Province is also one of the largest salt producers in China. To reduce the burden of hypertension, in 2011China’s National Health and Family Planning Commission (formerly the Ministry of Health) and Shandong provincial government, with technical assistance provided by US CDC, launched the first comprehensive salt reduction project in China: the Shandong Province & Ministry of Health Action on Salt and Hypertension (SMASH). The goal of SMASH is to: 1) reduce daily salt intake from 12.5 grams/day to 10 grams/day by 2015; and 2) improve hypertension control within the province.

In order to reduce salt intake, food labeling, reformulating local cuisine, distribution of scaled spoons for measurement of salt use in cooking, and food industry product reformulation are being broadly adopted. The initiative works with restaurants to develop sodium standards for Shandong cuisine, including, developing and conducting chef training and contests to provide lower salt menu items and recipes track salt usage, and disseminate educational resources. Restaurants that follow the lower salt requirement are designated a “Distinguished Restaurant”.

Philadelphia, also interested in reducing salt intake as part of its Get Healthy Philly initiative, launched the Philadelphia Healthy Chinese Take-out Initiative in 2012, a joint effort of the Philadelphia Chinese Restaurant Association, the Center for Asian Health of Temple University, the Asian Community Health Coalition and the Department of Health (DOH), to improve access to healthier food options. In an effort to control and prevent high blood pressure, the initiative aims to reduce the sodium content in Chinese take-out dishes by 10-15%. BetweenJuly, 2012 and April, 2013, 206 restaurants of more than 400 agreed to participate in the initiative. Philadelphia Healthy Chinese Take-out Initiative provided a series of free cooking trainings for owners and chefs on low salt cooking techniques. These included enhancing flavor with herbs and spices, using lower sodium ingredients such as reduced sodium soy sauce, modifying recipes to use ½ the amount of prepared sauce in dishes, and limiting distribution of soy sauce packets to customers. Marketing materials for owners and consumers to promote awareness of the initiative were also developed and distributed. DOH staff collected and analyzed samples of two popular dishes from 20 restaurants to assess changes in sodium content since the program began: preliminary results show an average of a 10% reduction in sodium content over the past two years.

After learning about US sodium reduction efforts via CDC’s Salt e-Update, SMASH officials have been working with Philadelphia Healthy Chinese Take-out Initiative to share information on their respective sodium reduction initiatives. Shandong shared CDC sodium fact sheets translated to Chinese with Philly, which assisted Philly in communicating with participating restaurant operators who only speak Chinese. Philly has provided Shandong with program insights and experience on monitoring and evaluation as well as program scope. Continued discussions will allow both communities to better communicate and share enhanced recipes, cooking techniques, and chef training materials with restaurants to reduce sodium in their menus. Expanded dialogue will also allow both projects to share lessons learned and fine tune efforts around training restaurants to reduce sodium, conducting public education campaigns focused on sodium reduction, and collecting baseline survey data to help inform targeted strategies for sodium reduction.

While the US continues to make progress in achieving our national CVD goals for sodium intake, there remains great opportunity to achieve more. Active engagement with global partners not only provides the unique opportunity to share our expertise and knowledge but to also leverage existing global efforts to enhance our knowledge and improve domestic approaches. SMASH and Philly’s Healthy Chinese Take-out Initiative share similar goals and approaches and are leveraging resources and experiences to enhance their respective programs.

To learn more:

• CDC Division for Heart Disease and Stroke Prevention
  The mission of the Division for Heart Disease and Stroke Prevention (DHDSP) is to provide public health leadership to improve cardiovascular health for all, reduce the burden, and eliminate disparities associated with heart disease and stroke.
• Sodium
  Most of the sodium we consume is in the form of salt, and the vast majority of sodium we consume is in processed and restaurant foods. Too much sodium can increase your blood pressure and your risk for a heart attack and stroke. Heart disease and stroke is the leading cause of death in the US.
• Sodium Reduction Toolkit: A Global Opportunity to Reduce Population-Level Sodium Intake
  The toolkit is designed to provide international and national government agencies and public health organizations with a brief overview, tools, and information for developing and implementing sodium reduction programs, policies, and initiatives aimed at lowering sodium intake. The toolkit offers seven self-guided modules, each about 30 minutes to complete. (Chinese modules are currently hosted on a Chinese site through US CDC China office.)
• High Blood Pressure
  High blood pressure is a common and dangerous condition. Having high blood pressure means the pressure of the blood in your blood vessels is higher than it should be. But you can take steps to control your blood pressure and lower your risk of heart disease and stroke.
• The Shandong Province and Ministry of Health Action on Salt and Hypertension (SMASH)
• Healthy Chinese Takeout Initiative

Did you enjoy this blog? Share it on Twitter!