SALT SMART CONSORTIUM13‐14 June 2013 PAHO, Washington DC

Experiences with research on consumer KAB regarding salt intake - methods instruments target audiencessalt intake - methods, instruments, target audiences

Hasan Hutchinson, Director GeneralOffice of Nutrition Policy and Promotion

Presentation Outline

• Applying the “Applying a Social Marketing Framework to Salt Reduction” to Health Canada’s Eat Well Campaign

I. Situation AnalysisII. Literature Review & ResearchII. Literature Review & Research

FindingsIII. Target AudienceIV. Audience AnalysisV. Supply SideyVI. Demand Side / Communication

Goal and ObjectivesVII.Marketing Mix StrategiesVIII.Monitoring & Evaluation PlanIX. Work Plan & TimelineX. Budget / Funding SourcesXI. Summary of Best Practices

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I. Situation analysis – Step A: Describe Background• Prevalence of hypertension

• Data from the Canadian Health Measure Survey (CHMS – 2007-2009) indicate that nearly one-fifth (19%) of Canadians aged 20 to 79, roughly 4.6 million people, had hypertensionhypertension.

• Another 20% had readings in the pre-hypertension range.

• Leading causes of death and disabilityg y• Cardiovascular disease

• Hypertension and Sodium IntakeHypertension and Sodium Intake• In Canada, it has been estimated that if the average sodium intake is decreased by

1,840 mg/day—roughly equivalent to bringing it down from the current intake to the AI of 1,500 mg/day—hypertension prevalence would be decreased by 30%.

• At-risk populations• Everyone is at risk

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Situation analysis – Step A, Con’t

Age Group Adequate Intake (AI) –

Upper Limit (UL) –

What Canadians

mg/day mg/day are eating*

Adult 1500 2300 3200*

Youth(9-13 years

1500 2200 3200*( yold)Children(4 8 ld)

1200 1900 2700*(4-8 years old)

* Not including the amount added in preparation or at table

4From Canadian Community Health Survey 2.2 (2004)

Situation analysis – Step A, Con’t

Data are based on the Canadian Community Health Survey - Cycle 2.2 on Nutrition, Statistics Canada, 2004.

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y y y , ,

Situation analysis – Step A, Con’t

Sources of Sodium

Diet5% added while cooking6% added while eating

FoodBreads – 14%Processed meats – 9%6% added while eating

12% from natural sources77% from processed

Vegetable products – 9%Soups – 7%Pasta dishes – 6%% p

foods Cheese – 5%Milk products – 4%Red meat products – 4%P lt 4%Poultry – 4%Gravies and sauces –4%

6From Canadian Community Health Survey 2.2 (2009)

Situation analysis - Step B : Current Nutrition Guidance & Legislation

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Situation analysis - Step B, Con’t

INGREDIENTS Wh l h t h t • Nutrition Facts

Canada’s Nutrition Labelling regulations:

INGREDIENTS: Whole wheat, wheat bran, sugar/glucose-fructose, salt, malt (corn flour, malted barley), vitamins (thiamine hydrochloride, pyridoxine hydrochloride, folic acid, d-

• Nutrition Facts

py ycalcium pantothenate), minerals (iron, zinc oxide).

• Ingredient List

• Nutrition Claims “Good source of fibre”

• Health Claims “A healthy diet…”

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Situation analysis - Step B, Con’t

The Nutrition Facts table since 2005

• Easy to find

• Easy to read

• On most prepackaged foods

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Situation analysis - Step B, Con’t

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Situation analysis - Step C: Gap Analysis

Key Education Gap: y p

Lack of consistent messaging and needmessaging and need to improve the health literacy of Canadians.

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II. Literature Review and research Findings

What is Research Saying?

Children • A high intake of sodium is associated with HBP

and is also likely to predispose children to develop h t i l t i lifhypertension later in life.

Ageing populationge g popu at o• The realities of an aging population with higher

rates of disease, and higher numbers of overweight have far-reaching social and financial g gimplications for peoples’ quality of life, and for Canada’s health care system.

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Research findings, Con’t

• The economic consequences of an unhealthy diet are significant and estimated at over $6.6 billion in g $1998 and growing.

• Research has shown that sodium reduction interventions are among the most cost-effective gways of reducing the burden of cardiovascular disease.

• It has been estimated that a reduction of 1800 mg gin the average sodium intake of Canadians would result in direct healthcare savings of $1.38 billion per year; including indirect costs, savings would be $2 99 billion per year$2.99 billion per year.

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III. Target Audience

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IV. Audience Analysis: What do Canadians believe?

• While 89% of Canadians believe that their fellow Canadians consume too much sodium,

• only 41% of Canadians think they consume too much themselves. y y

• 45% of Canadians believe they consume the right amount of sodium,• however only 24% monitor very closely the amount of sodium intake in their diet.

• Of the two-thirds of Canadians who say they take action on a regular basis to control their sodium intake, the top measures reported are to not add salt when cooking (42%) or at the table (40%).

• Consumers have no knowledge of the target daily amount of sodium (AI or UL).

• When asked 72% of Canadians think that salt in processed foods is• When asked, 72% of Canadians think that salt in processed foods is the single largest source of sodium in the Canadian diet,

• however only 16% report minimizing their consumption of processed foods and 14% report looking at the Nutrition Facts Table in an effort to control their sodium intake.

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Audience Analysis, Con’t: More beliefs…

• The best way to reduce the sodium in my diet is to stop using the salt shaker.

• I can't be eating too much salt becauseI can t be eating too much salt becauseI don't add it to my food.

• Food does not taste good without salt.

• You can tell what foods are high in sodium because they taste salty.

• Sea salt and “fleur de sel” are better for you than table saltSea salt and fleur de sel are better for you than table salt.

• If I cut down on the amount of salt I eat my body won't have enough.

• I don’t have High Blood Pressure, therefore I don’t need to watch my salt intake.

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V. Overview of supply

Nutrition Labelling Legislation

Work by the food industryTo decrease sodium in food products

Data on sodium in Canadian Food products and work of the Food Directorate to reduce sodiumIn the food supply

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VI. Communication goal and objectives

Sodium Reduction Awareness and Education Objectives

• To increase awareness that most people in Canada eat too much sodium and can benefit from reducing theirand can benefit from reducing their intake.

• To increase understanding and develop skills to reduce sodium intakedevelop skills to reduce sodium intake within the context of healthy eating.

• To reduce consumers’ intake of sodium in the context of healthy eating.in the context of healthy eating.

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Healthy Eating Awareness and Education Initiative

Healthy Eating with Canada’s Food Guide

2010/11 2012 2013 2014 2015Healthy Eating with Canada s Food GuideFoundation of the work

Phase 1: Healthy Eating & Nutrition Labelling N t iti F t Ed ti C i (NFEC) % D il V lNutrition Facts Education Campaign (NFEC) – % Daily Value messages

Phase 2: Healthy Eating & Sodium Reduction Eat Well Campaignp g

Phase 3: Healthy Eating & Healthy WeightsFocus on Food skills in support of the Curbing Childhood Obesity FrameworkObesity Framework

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Phase 1: Nutrition Facts Education Campaign

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Nutrition Facts Education Campaign

• Nutrition Facts Education Campaign in collaboration with Food & Consumer Products of Canada (FCPC)

• 34 participating food manufacturing companies• FCPC members: on-pack messaging (792M packages),

advertising and media partnerships (TVA and Shaw) and t h i th hi l ( b l tt )outreach in other vehicles (web, newsletters)

• Health Canada: provides messages and web based content and interactive tools

• Evaluation: To be completed in 2013/14• Evaluation: To be completed in 2013/14

Results 2009 – 2012use of the Nutrition Facts table (2010: 69%; 2012: 74%)• use of the Nutrition Facts table (2010: 69%; 2012: 74%)

• 54% awareness of the new % DV image• % DV awareness 48% changed shopping behaviour

21www.healthycanadians.gc.ca/dailyvalue

Phase 2: Sodium Reduction’t

• British Columbia’s Ministry of Health Dietitians of Canada and

’t

• British Columbia s Ministry of Health, Dietitians of Canada and EatRight Ontario (with support from Health Canada) led focus group testing with dietitians and consumers in Vancouver, Kitchener, Toronto and Ottawa; public focus group testing included participation from a variety of cultural and socio-included participation from a variety of cultural and socio-economic backgrounds.

• Health Canada led additional focus testing sessions in Halifax, M t l d Ed t t h th t ti f thMontreal, and Edmonton to enhance the testing of the messages and explore directions for “tone”. In each location, one session was held with the general population, and one session was held with Canadians with a lower socio-economic t t (l SES)status (low SES).

• Costa Rica has tested and adapted these messages.

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Key Findings with Consumers

• Sodium is generally not a top-of-mind aspect of healthy eating.• There is some confusion over the difference between salt andThere is some confusion over the difference between salt and

sodium.• Messages that provided new and specific information

resonated best with participantsresonated best with participants.• Among the messages that were tested, those that provided

statistical information had a strong impact.• Consumers are looking for practical and tangible tips• Consumers are looking for practical and tangible tips.• Messages need to be customized for cultural groups to ensure

using appropriate examples.F il h i i d di titi th t l• Family physicians and dietitians are the most commonly identified sources of information about sodium.

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Sodium Messages: Get the Facts

Fact: Sodium is found in salt.

Fact: We eat too much sodium.

F t E ti t h di bFact: Eating too much sodium can be harmful to our health.

Fact: Most of the foods we eat contain too much sodium.

More messages and tips @ HealthyCanadians.gc.ca/sodium

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VII. Marketing Mix StrategiesHealth Canada: Awareness & Education

Clear and consistent messages & campaign look & feel (carried by all)

Media

Parents of Public R l ti

Industry / Retail Parents of

children aged 2-12

RelationsRetail

Intermediaries/ PTs / NGOs

Web & Digital Engagement

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Web and Social MediaWeb & Digital Engagement

Major update and overall to consumer web content on new healthycanadians.gc.ca

152K unique page views (mid-Oct/12 – Mar/13)

1:30 average time on page1:30 average time on page

Banners on media partners driving traffic33K new visits from UTM coded banners

Coordinated Facebook & Twitter messages from HC, media and retail partners

26HealthyCanadians.gc.ca/EatWell

Health Canada Web SiteWeb & Digital Engagement

Healthy Eating Toolbox

g g

Healthy Eating Toolbox Information for Intermediaries

• The toolbox includes resources for intermediaries such as articles, quizzes, fact sheets, interactive tools, presentations, media relations and social media materialsmedia relations and social media materials from partners.

hc-sc.gc.ca/fn-an/nutrition/part/tb-bo/index-eng.php

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Broadcast - CORUSMedia

CONCEPT:

“The Wilsons Eat Well”: Kortney and Dave Wilson and their 3 children ylearn about healthy eating and sodium reduction

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TRANSCONTINENTALMedia

CONCEPT:

C di Li i d C d P i f ll 3 h h lthCanadian Living and Coupe de Pouce magazines follow 3 moms each on a healthy eating journey with advice from a dietitian. Included custom articles, print PSAs, 6 videos, blogging, “Ask an expert”, e-newsletters, quizzes, Facebook posts, Tweets and recipes.

29www.canadianliving.com/healthylifewww.coupdepouce.com/viesaine

Media Survey Highlights

OBJECTIVEGauge the recall of the campaign, and impact on behaviour, knowledge and understanding of healthy eating messages. Research was conducted throughout the campaign with all 3 media collaborators.

KEY CONCLUSIONSResults indicate that the media partnerships had an overall positive effect on attitudes towards healthy eating and intent to change healthy eating behaviours.

57% recall Wilson family vignette about making healthier food choices (Corus)

37% intend to change their healthy eating

Up to 48% recall for Astral vignettes

healthy eating habits (Corus/Astral)

20% of those exposed to the

i t

Average of 59% will choose sodium reduced foods

campaign ate healthy meals more often in March (Astral)

44% average recall of print articles

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Collaboration with Food Retailer AssociationsIndustry / Retail

• Retail Council of Canada members, Grocers Division• Canadian Federation of Independent GrocersCanadian Federation of Independent Grocers

• Focus on healthy eating and food skills messages such as planning, shopping and food preparation (highlighting meal plans, tips, tools, etc.)

Total Reach: 90%+ of grocery sales in Canada (est. 20M+ customers/ wk)

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IntermediariesIntermediaries / PT / NGOPTs / NGOs

Hypertension Canada

Chronic Disease Prevention Alliance of Canada

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Provinces and Territories – The BC Example

Fact Sheets –Integration of Sodium MessagesMessages

Social Marketing CampaignWith posters and other resources

Interactivity – Build a Low Sodium Menu

other resources

33www.healthyfamiliesbc.ca

Figure 1: HEAEI Logic Model

VIII. Monitoring & Evaluation PlanFigure 1: HEAEI Logic Model

Eating Well with Canada’s Food Guide

Inputs Acts, regulations, policies, priorities

Facilities/Infrastructure Human resources Funding Science and Technology

Research Data

Foundation Eating Well with Canada s Food Guide

(A2) Outreach to and (A3) Negotiate and (A4) Develop campaign (A1) Assess awareness,

knowledge and behaviour (A6) Monitor, (A5) Disseminate

Components Healthy Eating/Nutrition Labelling NFEC

Healthy Eating/Sodium Reduction Healthy Eating/ Healthy Weights

Foundation

Activities selection of potential partners

develop partnerships components

knowledge and behaviour of target audience;

identify focus; and plan initiative

conduct surveillance and Evaluate

information and resources;

implement campaign

Outputs Awareness and education activities, tools and resources

Process Evaluation

Target Audience

Delivery Partners Government (FPT), Industry, NGOs, Media, Health Professionals

Immediate Outcomes

Primary: Parents and Caregivers of Children aged 2-12

(B1) Canadians are aware of and have access to healthy eating guidance

Secondary: Intermediaries such as health professionals and NGOs

(B2) Integration of the CFG and the HEAEI messaging into nutrition education and food environments across Canada

(C1) Canadians are knowledgeable about and understand healthy eating: label reading, sodium reduction, and food skills

(C2) Canadians make informed, healthy eating decisions

Ultimate Outcome (D1) Healthy Canadians

Intermediate Outcomes

Outcome Evaluation

34HEAEI Evaluation Framework

Sodium reduction is a sharedis a shared

responsibility amongst food

industry, fed/prov/terr

tgovernments, NGO’s,

intermediaries andintermediaries and consumers.

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XI. Summary of Social Marketing Best Practices

1. Identify one segment of th “ bli ” h

Let your taste buds enjoy the “public” whose

behaviour you hope to influence

j ythe flavour of food with less sodium!

2. Think like a consumer3. What do they get in

t ?return?4. Change does not occur

over nightover night5. Surprise them!

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Thank you!Contact information:

Hasan.hutchinson@hc-sc.gc.ca

Eating Well with Canada’s Food Guide www.health.gc.ca/foodguide

Eat Well and Be Active Educational toolkit www.health.gc.ca/eatwell-beactive

% Daily Value h lth di /d il lwww.healthycanadians.gc.ca/dailyvalue

Sodium Reduction www.healthycanadians.gc.ca/sodium

EAT WELL campaign www.healthycanadians.gc.ca/eatwell

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Sample Tips – At the Grocery Store

Read the information on food packages• Buy unsalted and lower sodium foods

whenever possible. Look for words such

Make wise choices from the four food groups in Canada’s Food Guide

e e e poss b e oo o o ds sucas “sodium-free”, “low sodium”, “reduced sodium,” or “no added salt” on the package.

• Compare food labels. Buy the products f

• Vegetables and Fruit - Buy fresh or frozen vegetables whenever possible. Look for canned vegetables that are low in sodium. Buy low sodium vegetable

with the lowest amounts of sodium.• Look for foods that contain less than 360

mg of sodium per serving.• You can also use the % Daily Value

(%DV) on the label to compare products

y gjuice and tomato juice.

• Grain Products - Choose breads, breakfast cereals, and bakery products

(%DV) on the label to compare products and see if the food has a little or a lot of sodium. Choose a product that has less sodium, look for one with a sodium content of less than 15% DV.

that are lowest in sodium. Enjoy a variety of grains such as barley, quinoa and rice which are naturally sodium free.

5% DV or less is a little15% DV or more is a lot.

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Sample Tips – At HomeMake healthy meals and snacks• Eat fewer packaged, ready-to-eat and take-out foods. • Make your own soups, sauces and salad dressings.

E j bl d f i U f h f i d f d• Enjoy more vegetables and fruit. Use fresh or frozen instead of canned whenever possible.

Reduce the sodium in the foods you usey• Rinse canned vegetables and canned beans, peas and lentils to wash away

some of the sodium. • Use less of the seasoning that comes with taco kits, packaged macaroni and

cheese pasta and rice mixescheese, pasta and rice mixes.

Add flavour without sodium• Flavour foods with herbs and spices. Here are a few ideas: p

• Basil - tastes great with tomatoes and pasta • Cumin – adds flavour to soups, stews and sauces

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Sample Tips – When Eating Out

Make lower sodium menu choices• Order smaller portions or share with someone.

f “• Ask for gravy, sauces and salad dressings “on the side”, and use only small amounts.

• Flavour your food with lemon or pepper instead of adding salt, sauces or gravygravy.

Find the best menu choices • Check the nutrition information• Check the nutrition information of menu items before you order and choose foods with less sodium. This information may be in a poster orinformation may be in a poster or pamphlet at the restaurant or on the restaurant’s website.

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Additional Sodium-Related Resources

Dietitians of Canada: • www.eatracker.ca• www.eatwise.ca

Hypertension Canada Education Section• www.hypertension.ca

Canadian Stroke Network• www.sodium101.ca

Champlain Cardiovascular Disease Prevention NetworkChamplain Cardiovascular Disease Prevention Network• www.giveyourheadashake.ca

Heart and Stroke Foundation of Canada• www.heartandstroke.com

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