Speed-up salt reduction by increasing the urgency to reduce salt intakes

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Speed-up salt reduction by increasing the urgency to reduce salt intakes

IUNS-Unilever partnership on salt reduction; progress report and outlook

1.1 Aim of partnership

1.2 Main activities in 2012-2013

1.2.1 Consumer surveys

1.2.2 Consumer behaviour change workshops

1.3 Evaluation
4.1 Workshop format

4.2 Workshop challenge; how to bring people to the next stage of change?

4.2.1 Make it understood

4.2.2 Make it easy

4.2.3 Make it desirable

4.2.4 Make it rewarding

4.2.5 Make it a habit
5.1 Public Health Campaigns on salt reduction; what should be the focus?

5.1.1 Overcoming misperceptions about low salt

5.1.2 Bridging the gap between recommended and actual salt intake

5.1.3 Making salt reduction personally relevant

5.1.4 Helping people to actively consider low salt food choices

5.2 Public Health campaigns; who should lead?

APPENDIX 1: The Netherlands, Dec 2, 2011

APPENDIX 2: United Kingdom, Dec 9, 2011

APPENDIX3: Austria, May 4, 2012

APPENDIX 4: Hungary, March 14

APPENDIX 5: South Africa, 22-23 May, 2012

APPENDIX 6: India, September 21, 2012

APPENDIX 7: China, June 15th -16th, 2012

APPENDIX 8: Brazil, November 12, 2012

Speeding up salt reduction by increasing the urgency to reduce salt intakes

IUNS-Unilever partnership on salt reduction; progress report and outlook

1.1 Aim of partnership

Current salt intake is in the range of 8-15g/day. To prevent the age-related increase in blood pressure and associated risks for heart disease and stroke, health authorities recommend intakes as low as 5-6g of salt per day. Since salt reduction is a Public Health target in most countries and Unilever has committed to global salt reduction targets for its products (http://unilever.com/images/USLP-Progress-Report-2012), Unilever reached out to the IUNS, who unites the local nutrition societies. Within Unilever’s ongoing ‘consumer connect’ partnership with the IUNS, Unilever agreed to 1) organize global salt reduction surveys amongst consumers, with input from the IUNS, and IUNS agreed to 2) organize salt-reduction behavior change workshop with Public Health experts, facilitated by Unilever.

1.2 Main activities in 2012-2013

1.2.1 Consumer survey

Objectives: 1) produce local insights on perceived salt intakes and contributions to salt intakes of different foods and discretionary salt; 2) produce a classification in subgroups according to stage of behaviour change and intention to change 3) identify preferred source and medium to promote salt-reduction.

Unilever agreed to conduct, in 2012, 6 consumer surveys around the globe. IUNS and Unilever agreed to focus on Hungary, Austria/Germany, South Africa, India, China and Brazil. In 2013, a survey conducted in the US was added. Within each country a sample of 1,000 adults filled out an on line questionnaire. The questionnaires were adapted to local foods and habits by local IUNS representatives and Unilever country nutritionists.
1.2.2 Consumer behaviour change workshops

Objective: 1) bring together a wide range of Public Health stakeholders; 2) develop new salt reduction behaviour change approaches, based on consumer insights; 3) agree on follow up actions.

Based on two pilot workshops in The UK and The Netherlands, Unilever developed a salt reduction behaviour change workshop format, which was jointly rolled out by IUNS and Unilever to the 6 countries who conducted the salt-reduction consumer surveys in 2012. The IUNS invited a wide range of local Public Health stakeholders to the workshops, ranging from experts to (N)GOs and trade organisations.
1.3 Evaluation

Based on the 7 consumer surveys, 8 behaviour change workshops, a first joint publication on the consumer survey in Appetite, various presentations and meaningful new insights, the partnership-focus on salt can be considered a success.

However, as long as the large majority of people around the globe still are in an early stage of behavior change with respect to salt reduction, local Public Health campaigns aimed at increasing the perceived urgency to reduce salt intakes are needed more than ever. Effective salt reduction campaigns should focus on (local) target audiences and should involve a wide range of health influencers, who are clear on their roles.  


Current salt (sodium chloride) intake is an established risk factor for hypertension and related cardiovascular diseases. More specifically, current high sodium intakes is associated with an age-related increase in blood pressure and also is significantly associated with an increased risk of stroke, stroke mortality, and coronary heart disease mortality. Furthermore, there is clear evidence from intervention trails that by reducing sodium intakes, blood pressure in the general population can be reduced. The health benefits of sodium reduction apply to all populations, and not just the ‘salt sensitive’ or elderly. As there is consensus on the need to reduce sodium intakes, WHO and most of the local Health authorities are recommending reducing salt (sodium) intakes from an average of 9-10 g to 5-6 g salt per day. WHO advocates salt reduction in foods as a cost-effective strategy to improve public health. 

Based on the advice to reduce salt levels to 5-6 g per day, Unilever developed a set of product group-specific criteria to reduce salt levels in foods. Aim is to help consumers to reduce their salt intake to reach the interim intake goal of 6 g/day and the ultimate goal of 5 g/day, as is recommended by WHO. Modeling results using dietary survey data have shown that with current product criteria total daily salt intake in populations can be reduced by 25-30%. The results also show that the salt reduction criteria set a clear direction for industry-wide salt reformulation. However, equally clear is that these silent salt reformulations alone will not bring the interim and ultimate salt reduction targets within reach.

Salt reduction should, therefore, not be limited to silent product reformulations, as this is a slow process that has to follow the gradual taste adaptation of people from current high-salt preference to a lower-salt preference. This preference for high-salt foods is linked to the traditional use of salt in food preservation, cooking practice and dietary habits and often is supported by misperceptions about salt, explaining why in developing countries (e.g. India, China) salt intakes can be considerably higher than in developed countries.

To speed up salt reduction, an increased availability of great-tasting consumer-appealing, lower salt choices should be combined with effective behaviour change approaches aimed at:

  • increasing awareness amongst consumers about the benefits of salt reduction, correcting misperceptions about salt and educating on intake and main sources

  • making it easy and attractive for consumers to actively choose lower-salt foods or recipes whilst reducing the use of discretionary salt

  • Showing the benefits of a low salt diet and creating a supporting environment for low-salt choices

Achieving these goals is a shared responsibility of health authorities, academics and (N)GOs and also food manufacturers, restaurants & chefs and consumer interest groups.


The IUNS-Unilever global salt reduction survey analyzed people's perceptions, knowledge, attitudes and (self-reported) behavior. The study revealed that participants largely underestimated their individual salt intake and they also showed difficulties in identifying the main dietary sources of salt. Respondents further contradicted themselves as they showed low interest in salt reduction while, at the same time, such behaviour (i.e. salt reduction) was perceived as healthy and important. Based on these findings, the IUNS and Unilever authors advise to develop global intervention programs for salt reduction, including nationally tailored strategies to engage and interest consumers. See link to publication in Appetite.

Eight different country cohorts took part in this study (Germany, Austria, USA, Hungary, India, China, Brazil, and South Africa) with an overall sample of 6,987 respondents, aged 18-65 years. People were recruited from an international panel and were asked to fill in an online questionnaire. Only respondents without major health problems were included in order to avoid distortion of results due to special dietary behaviour. The questionnaire assessed perceived and estimated salt intake, main sources of salt in one's diet, knowledge, beliefs and attitudes about salt recommendations and 'who' respondents thought was responsible for reducing salt intake. Additionally, preferred methods of communication were explored. A standard questionnaire was developed and then adapted to local needs and culture.

Across all countries, average salt intake was shown to exceed national recommendations. Using a food-frequency questionnaire specifically developed for this study, the authors could show that, on average, and for the majority of the countries, the biggest proportion of salt intake comes from 'home foods' (i.e. salt containing food groups, salt added during food preparation, and salt added at the table), rather than 'out-of-home foods' (i.e. restaurant food, take away, and street food). Almost half of all participants expressed the belief that the main source of salt is the one added during cooking. Calculating dietary sources of salt based on their food-frequency questionnaire, however, the researchers could show that this was incorrect as the salt containing foods were the major contributors to respondents' salt intake (51%). With regards to people's motivation to reduce salt intake, large country differences were observed in the study. Respondents from China and Brazil showed the highest interest in salt reduction (83% and 81% respectively), while the German and Austrian sample reported the lowest intention in making any changes over the next 6 months: over half of respondents were not planning on reducing their salt intake.

Generally, the majority of participants were not aware of national recommendations for salt intake, despite the fact that salt reduction was recognised as a healthy and important behaviour. However, those respondents who knew about the effects of salt consumption on health displayed a more positive attitude towards salt reduction. When asked whose responsibility it is to reduce salt intake, across all countries participants rated themselves as being mainly responsible, followed by food manufacturers, restaurants and supermarkets. With regards to information search behaviour, medical staff (e.g. doctors or dietitians) but also labels on food packages were reported as the preferred sources of information on salt reduction, while TV, social websites and newspapers were rated the preferred media channels.

Based on this study it was concluded that future interventions should focus on educating people about the main sources of salt in one's diet and how to better estimate their own salt intake. Raising awareness of, and interest in, this topic is seen as crucial, given the general lack of motivation of participants to change their dietary behaviour (i.e. reducing salt intake). Furthermore, future policies not only need to take into account the role of the individual in changing one's behaviour but also the importance of external influences which can either encourage or inhibit people to adopt salt reduction practices. With regards to the best communication methods, the most accessible channels (TV and internet) should be used in reaching the population, taking into account local specificities and characteristics of the consumer.

The joint IUNS-Unilever behavior change workshops served as a first step in engaging relevant local stakeholders in jointly increasing consumer awareness on the need to reduce salt intakes with new and compelling behaviour change approaches. Behaviour change workshops were organized in The Netherlands, UK, Austria, Hungary, South Africa, China, India and Brazil. The Local IUNS contacts were our partners in bringing together relevant local health influencers, ranging from public health experts and health care professionals to representatives of governmental bodies or trade organizations. The workshop format was based on the ‘stages of change theory’, which describes an individual’s readiness to move to a next level of health behaviour. It was assumed that the slow implementation of public health advice on salt reduction is partly due to current focus on increasing awareness about public health risks, without properly identifying and targeting the perceived barriers for individual behaviour change.
4.1 Workshop format

The proposed workshop format included a “consumer shoes” role play (participants playing consumers) combined with a video recording of real consumers discussing salt. It was followed by a presentation on the theory of behaviour change and a presentation on country-specific insights (IUNS-Unilever consumer survey) on salt intake, perceptions and attitudes towards behaviour change. This was used as input for workshop brainstorms on new approaches to influence salt intake behaviour.

A typical full-day workshop had the following flow:

  • Welcome by IUNS and Unilever

  • Moderator to guide round of introductions & expectations and share agenda, house rules, background and objectives of the workshop

  • ‘Consumer shoes’ role play, where participants imagine they are a typical consumer and answer questions as they think that person would do

  • Watching a DVD of consumers (the same as were played before by participants) talking about salt reduction

  • Participants discussing and evaluating the big gap between what they thought consumers would say and what they actually said

  • First round of idea generation on changing salt intake behaviour based on consumer insights

  • Presentation on the behaviour change theory and introduction of Unilever’s ‘5 levers of Behaviour Change model’

  • Presentation on results of the local consumer survey on salt

  • Structured brainstorm (‘5 levers of change’) focused on making salt reduction ‘understood’, ‘easy’, ‘desirable’, ‘rewarding’ and ‘part of daily habits’

  • Participants divided into groups of 3-4 people with the objective of developing new concepts to address the main consumer barriers for change

  • Plenary presentations of the various groups on their ideas for new salt reduction approaches

  • The various groups work (with cartoonist) on the further development of their concepts

  • participants discussed how they to bring the workshop outcomes a step further

  • Closure

The learning objective of the workshop was for participants to be aware of the consumer perspective/misperceptions on salt, to have learned about the theory of behaviour change, obtained insights into what are the key local consumer barriers for reducing salt intake and to generate practical ideas on ways to overcome these barriers. In addition, the workshop should be successful in making participants enthusiastic about new approaches to address health behavioural change and motivating them to apply this in their public health-related work, preferably in close cooperation with other workshop participants.

4.2 Workshop challenge; how to bring people to the next stage of change?

The 8 workshops have been successful in bringing together a multi-disciplinary, multi-sector group of stakeholders in public health. These local workshop participants, often meeting each other for the first time, showed a keen interest in jointly developing new salt reduction approaches, based on consumer insights. Even though the workshop format addressed all stages of behaviour change, (make it understood>make it easy>make it desirable/rewarding>make it a habit) most of the workshops actually focused on the first stages of behavior change, i.e. increase awareness on the need to reduce salt intake (“Make it understood”) . See detailed workshop outcomes in APPENDIX 1-8.

      1. Make it understood

As most countries are in an early stage of change towards salt reduction, the biggest behaviour change challenge is to increase awareness about the gap between recommended and actual intakes and the benefits of salt reduction, whilst correcting misperceptions. This is the area of Public Health campaigning.

Identified key challenges are to make people realize that high blood pressure is a personal health issue and not just a public health issue and that high blood pressure is not a fact of life, but can be prevented. Before people will be ready to accept these messages, however, considerable hurdles need to be overcome, e.g. correct misperceptions about the impact of low salt intakes (causes white hair, results in too low blood pressure, experts don’t agree, etc.) and increase awareness about the gap between recommended and the actual personal salt intake.

Various ideas to promote salt reduction for specific audiences were generated, with key roles for Academics/IUNS and (N)GOs to ensure coherence of salt reduction messages. Based on the consumer survey, the medical community would be the most impactful messenger on the benefits of salt reduction and television and, increasingly also, on line social websites, the preferred medium.

      1. Make it easy

Taste was an important topic in all workshops and the link between less salt and less taste was considered an important barrier for change. The physiological link between ‘taste & salt’ can be addressed by a gradual and unnoticed reduction of salt levels in out-of home and in-home foods, giving taste buds time to adjust. Chefs were seen as the main authority to address the perceived/psychological link between taste & salt; Traditional chefs may be a barrier for change, but modern, health conscious chefs are best positioned to change consumer perceptions on the taste & salt link.

Many ideas to overcome the perceived taste barrier were developed, e.g. don’t let your taste be spoiled by salt (S-Africa), lowering salt to discover the true taste of foods (India), taste appears where salt disappears (The Netherlands), learn to like the real/natural  taste of (low salt) foods (the Netherlands and UK), don’t start the salt habit (UK), less salt, more meat (Austria), herbs and spices instead of salt (Hungary), don’t let salt spoil the natural flavour of foods (China), step-by-step approach to reduce salt in food without taste impact (e.g. China) and less salt, more flavor (Brazil).

Other ideas that could make it easier for consumers to reduce their salt intakes were e.g. balancing salty foods with light/low salt foods (e.g. vegetables), eating less snacks and less out of home, standardization of amounts of salt (e.g. pinch or spoon) added to foods during cooking, labeling of the salt/sodium content on food products, inspiring t.v. chefs promoting low salt recipes and online/websites to track saltiness of recipes.

      1. Make it desirable

Role models and peers who share their experience with salt reduction can make it attractive and aspirational for consumers to reduce their salt intakes. They can feature in targeted Public Health campaigns and food industry-led campaigns, using traditional media channels as well as social media.

Instead of emphasizing the need for salt reduction, these campaigns could promote the natural/real taste of lower salt foods, with proposed messages such as “less salt, more herbs”, “grow your own herbs” and “offer your family the real taste of foods”

      1. Make it rewarding

Health care professionals can monitor the impact of salt reduction on blood pressure; positive results will motivate patients/client to continue.

One of the proposed campaign ideas was an appeal to mums, as family health influencer, to take responsibility for reducing salt intakes and preventing salt-addiction of children. Another idea was to campaign against adding salt on the table as it is not very motivating/rewarding for the cook.

      1. Make it a habit

The far majority of people are still far away from habitual low salt food choices, but for early adapters it is important to be able to make ‘informed’ low salt food choice, requiring labeling of the salt content on pack, on restaurants menus and on recipes.

Obviously, there is an important role for the food industry and restaurants in supporting sustainable salt reduction behavior by providing a wide variety of preferred, clearly labeled, lower salt foods, supported by compelling salt reduction messages.    


In spite of the scientific consensus on the benefits of salt reduction and the big gap between recommended and actual salt intakes, the majority of people is not (yet) considering to reduce their salt intake. What’s holding them back is not a lack of awareness about the link between salt and blood pressure, but they:

  • have misperceptions about low salt

  • are not aware of the gap between recommended and actual salt intake

  • do not believe salt reduction is personally relevant

  • are not actively considering low salt food choices

These consumer insights should be taken into account in Public Health campaigns.

5.1 Public Health campaigns on salt reduction; what should be the focus?

5.1.1 Overcoming misperceptions about low salt

  • “Scientist don’t agree” whereas there is consensus & recommendations

  • “Only for hypertensives/salt sensitives” whereas relevant for everyone 

  • “Gourmet salts are ok” whereas only low sodium salts are ok

  • “Low salt intakes associated with grey hair, low immunity,..” Not true  

  • “Foods labeled as lower-salt are less tasty” Perceived, not necessarily real

  • “My body is craving for salt” Not quite true, only taste buds are

  • “Salt linked to health (iodine, hygiene, ORS,.) ”Technical solutions possible

  • “My intake is fine” whereas current salt intakes are much too high

      1. Bridging the gap between recommended and actual salt intake

  • What are the main dietary sources of salt, in home and out of home

  • How much salt is added during cooking and at the table

  • The gap (factor 2-3) between recommended and actual salt intake

5.1.3 Making salt reduction personally relevant

  • People to have their blood pressure checked, with repeat appointments

  • For the age-related increase in blood pressure linked to high salt intakes

  • For health risks, i.e. stroke/heart disease, linked to high blood pressure

  • Young people for high blood pressure and its complications  

5.1.4 Helping people to actively consider low salt food choices

  • Via all available channels that salt reduction is beneficial for everyone

  • The taste enhancing role of salt, but not its salty taste

  • Tasting of foods before adding salt, during cooking and at the table

  • Swopping high salt foods with preferred low(er) salt alternatives

  • Adjusting salt levels of meals to users with the lowest salt preference

  • Growing herbs & spices to replace salt during cooking

5.2 Public Health campaigns on salt reduction, who should lead?
At ICN, Granada, conference delegates (n=1500) were asked “In stimulating consumers to change to more healthy behaviours, where should the different stakeholders play a role?”  The conference delegates had to rank the different health influencers over the three (clustered) behaviour change stages (scores of Academics, NGO’s, etc adding up to 100%). The results were surprisingly clear:

  • Government and Academic should take the lead in educating consumers, i.e. make it understood.  

  • The Food industry, restaurant & chefs were given a key role in making it ‘easy & desirable‘ for consumer to change habits.  

  • HCP’s, Academics and NGOs should team-up to make behavior change  rewarding & a habit.

Based on finding from the ICN survey, Governments and Academics/IUNS, supported by other health influencers, should be leading in Public Health campaigns aimed at making consumers understand the urgency of salt reduction.

Salt reduction consumer surveys combined with behavior chance workshops - attended by health influencers, can provide the basis for consumer-focused salt reduction campaigns. However, considering the fact that the majority of people in most countries are not thinking of reducing their salt intake, the main focus of these salt-reduction campaigns should be on education, i.e. ‘make it understood’. This allows for the surveys and workshops to be narrowed-down to serve this purpose.
The ultimate goal of these educational campaigns would be to convince people to consider / plan a switch towards lower salt food choices. This will boost consumer demand for lower salt foods and in parallel it will trigger food industries and restaurants to increase the availability of preferred lower-salt food choices, promoted by compelling messages.
Speeding–up salt reduction around the globe will require a focus on local target audiences and should involve a wide range of local health influencers, who are clear on their roles.


What follows is an overview of the 8 salt-reduction workshops jointly organized by IUNS-Unilever in The Netherlands and UK, in 2011, and Hungary, Austria, S-Africa, India, China and Brazil, in 2012.

APPENDIX 1: The Netherlands, Dec 2, 2011
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