1

Stakeholder and Expert Perspectives on Dietary Sodium Reductions

in Thailand, 2017 Jahn Jaramillo, WHO Intern, M.P.H. Candidate, University of Washington

Summary Background As part of the global and national strategy for prevention and control of noncommunicable diseases

(NCDs), Thailand has set targets to reduce the prevalence of raised blood pressure by 25% and decrease population intake

of sodium by 30% by 2025. Passage of a resolution on sodium reduction by the National Health Assembly in 2015, and

development of a national strategy of reduction of Salt and Sodium Consumption (SALTS Strategy 2016-2025),

demonstrate Thailand’s commitment to reducing the risk of heart disease and other related chronic illnesses. The

perspectives of stakeholders and champions in the field of NCDs and salt reduction are imperative for ensuring optimal

operationalization of the current salt strategy. The aim of this report is to provide an up-to-date scan of the landscape and

ongoing research in the field, to identify barriers to policy implementation, and to obtain key recommendations from

national stakeholders and experts. The report intends to expand available information on salt reduction in Thailand to

showcase ongoing efforts and offer ways to strengthen national initiatives.

Methods Available literature on salt reduction in Thailand were accessed in order to assess the current situation. In-depth

interviews with national stakeholders and experts were also conducted. Interviewees were asked about perceived

challenges to effective policy implementation, recommendations to overcoming barriers identified, and ongoing research

in their field. Barriers and recommendations obtained were reviewed.

Findings A total of 8 studies were found from 2009-2016 that measured sodium intake and dietary sources in Thailand to

date. In total, 15 salt experts and stakeholders were interviewed representing academia, government, and the industry

sectors. National stakeholders and experts identified barriers to implementation of the SALTS Strategy in the areas of:

prioritization of interventions and leadership, inter and intra agency collaboration, marketing and health promotion,

industry approach and timing, and research priorities. Stakeholder recommendations were categorized in monitoring and

evaluation, policy and strategy, consumer education and behavior modification, and research. There was clear consensus

that the strategy was relatively new and gaining momentum.

Value This report identifies current existing literature on sodium research and describes barriers to – and

recommendations for – advancing sodium reduction policy implementation in Thailand from the perspectives of experts

and stakeholders.

Interpretation Effective implementation of the action plan under the sodium and salt reduction policy will require

continuous surveillance, monitoring and evaluation activities, bridging the strategy with other national initiatives,

increased coordination amongst diverse stakeholders, prioritization of interventions focused on street food/food shops, and

additional investment in food science, nutrition research, and consumer education.

Introduction Non-communicable diseases account for 70% of all

deaths worldwide1, with a similar pattern occurring in

Southeast Asia2. In Thailand, hypertension is a major

cause of cardiovascular disease (CVD)3,4,5

, which kills

17 million6 people each year. In particular, higher levels

of sodium intake as part of an unhealthy diet are

associated with elevated blood pressure, a leading risk

factor for CVD and premature death. The World Health

Organization (WHO) has set a global target of less than

5 grams7 of salt per person in order to improve

population health. However, overconsumption of salt is

prevalent worldwide8 as evidenced by global estimates

placing Thailand at 13.5g/salt per day9.

Between 2010-14, over 70 countries10

reported national

salt reduction mechanisms in a concerted effort to meet

global targets, including Thailand. Thailand’s

multipronged SALTS strategy11,12

is focused on

developing the stakeholder network, mass awareness

campaigns, legislation, technology, and surveillance.

The goal of the strategy is a 30% relative reduction of

population sodium intake by 2025 in accordance with

WHO guidelines.

2

Latest initiatives have included mandatory nutrition

labeling and Guideline Daily Amounts (GDA) on

specific food products13

and the launching of the

Healthier Choice Logo14

– a voluntary approach

encouraging companies to reformulate their food

products. The development of a Thai food database15

comprising of an inclusive list of food products and their

corresponding nutritional value; the technological

development of a salt meter measurement tool16

;

consumer phone scanning applications17

; and the

implementation of Healthy Food Menus18

in food shops

have been new innovations.

The evolution19

of salt reduction developments in

Thailand position the country as a regional leader in

preventing unnecessary lives lost due to CVDs20

. As

Thailand joins other global champions in managing high

salt intake and its deleterious implications, current expert

and stakeholder input can help guide implementation of

the comprehensive national-level Salt and Sodium

Reduction Strategy.

Rationale and Study Aims Thailand continues to develop rigorous research in the

field of salt and sodium reduction to influence policy

formulation. A compilation of recent and ongoing

research can offer those interested in Thailand’s efforts

access to current developments. As the action plan’s

initiatives begin to roll out, expert recommendations are

vital to ensuring the effective operationalization of the

national salt reduction framework. The aim of the study

is to assemble literature on sodium intake and sodium

sources in Thailand, and to identify barriers to

implementation of the SALTS strategy. It seeks to

provide recommendations, particularly with respect to

achieving national and global goals, from the

perspectives of stakeholders.

Methods Data Sources Most information collected was publically available.

National policy documents and surveys were retrieved

from official government websites and WHO.

PowerPoint presentations were obtained from experts.

Research studies were accessed through PubMed. Other

information was accessed through websites of national

stakeholders and internet searches.

Review of Literature Online searches of government, stakeholder, and WHO-

related websites were conducted on salt and sodium

reduction in Thailand. Efforts were followed up with

thorough scanning via PubMed. Search terms included:

sodium, salt, consumption, Thailand, Southeast Asia,

public health, survey, intake, sources. Researches were

chosen based on three criteria: relating to sodium

intake/sources, year, and whether they were previously

included in global reviews of sodium reduction

initiatives in Southeast Asia.

Interviews Semi-structured, in-depth interviews were conducted

during October-November 2017. National stakeholders

and experts were identified by a prominent Thai salt

champion. Requests for interviews were sent via email

and those who responded were interviewed. The

literature review informed open-ended questions on the

following topics: government response, attitudes towards

current sodium reduction legislation, perceived

obstacles, challenges and barriers, perceived strengths,

best practices and ways forward, and ongoing research.

Interviews were conducted in the offices of experts.

Notes were taken in the place of a recording device due

to cultural expectations. Attempts were made to reach

out to a diverse pool of stakeholders and experts in order

to ensure an array of opinions.

Results Literature Review

A. SODIUM INTAKE

A total of 8 studies were identified from 2009-2016 that

measured dietary intake of sodium through urine

analyses21,22,23,25

and dietary recalls9,26,27,29

(Table 1).

Several small scale studies measured sodium intake in

high-risk groups through 24-hour-urine (24hUNa) or 12-

hour overnight measurements. The strongest study21

comprised of 200 24hUNa samples selected from 8

districts in 4 regions of Thailand to assess population

sodium intake. 2 comprehensive studies26,27

utilizing

nationally representative samples were also conducted

(Figure 1).

A review30

of salt intakes in Southeast Asia estimated

sodium intake levels at 4.9g (12.3g) and 3.3g (8.3g) for

younger and older adults in Thailand, respectively. The

study concluded higher than recommended sodium

intakes across all population segments studied based on

research assessed from 1960-2009. The review contained

limited information on Thailand and was used as a

reference point to locate publications to date from 2009

onward to further complement previous efforts of

collection.

I. Based on Urinary Na Measurement

A 2012 study21

assessing the situation of sodium intake

in the Thai population measured 24hUna in a subset of

participants at 128.50 mmol/day (2,955mg) with 87.5%

of participants estimated at over 100 mmol/day

3

(2,300mg). Samples were obtained from a nationally

representative pool of 2,226 Thais aged 15-59 across

Northern, Northeastern, Central, and Southern regions.

Smaller-scale studies estimated sodium excretion among

various Thai participants22,23,25

ranging from 6 – 10g of

salt intake per day, with those at-risk for CVD23

and

hypertensive patients22,25

on the upper limits.

II. Based on Dietary Recalls

Thailand’s 2009 Study of Sodium Chloride (NaCI)

Consumption Among Thai People26

– the largest national

sodium survey thus far31

– indicated that Thais

consumed an average of 10.8 grams of salt (4,320 mg

sodium) per day. At more than double the WHO

recommended level, the main sources of salt derived

from salt added during cooking, packaged food, and

street food. The analysis indicated that salt intake in the

population came directly from condiments (8g), natural

food (2g), and ready to eat meals (0.8g) through the way

of sodium glutamate and sodium chloride32

.

An analysis of sodium chloride content in food

products33

identified the top 5 household condiments as

fish sauce (11.59g), soy sauce (3.15g), salt (3.05g),

shrimp paste (2.9g), and oyster sauce (2.17g) per person

per day. It also categorized instant noodles with

condiments, canned fish, mackerel, steamed chili, and

parsley as the most consumed household foods.

Samples obtained from the 4th National Health

Examination in 201127

measured sodium chloride

consumption in a subset of the Thai population,

reporting slightly lower levels. This difference was

attributed to dissimilar methods and the number of

provinces used to collect data. However, researchers

similarly concluded population intake over suggested

levels. Other studies29

found salt consumption over

5gs/day.

B. FOOD DATABASE

The 2016 Thai Food Composition Tables (FCTs)15

comprised of newly analyzed data with over 1,700 food

items distributed across 16 food categories, each with a

maximum of 27 nutrients including sodium. Published

by Mahidol University’s Institute of Nutrition, the

database is the first English edition of food composition

tables in Thailand. As a tool to determine the potential

contributions of foods to diet, the archive has been

leveraged to engage industry on practical reductions of

certain foods. Instant noodles, fermented fish, seasoned

snacks, fish sauce, soy sauce, and food pastes (chili, fish,

shrimp, curry) are among the frequently consumed foods

with the highest sodium content (Figure 2). Significant

variation in sodium content within the same food

categories were observed – e.g. foods within the Spices,

herbs, condiments, and seasonings category fall within

1,438 – 16,000mg – indicating scope for reductions

(Figures 3, 4).

C. GOVERNMENT RESPONSE: POLICY

INTERVENTIONS

In December 2015, the 8th National Health Assembly

endorsed a resolution entitled "Policy on reduction of

salt and sodium consumption to reduce NCDs”. Seven

recommendations from the assembly specified the main

directions for the current national salt reduction policy

passed the following year. The recommendations

directed the establishment of a national coordinating

mechanism, food standards and regulations, food

labeling, measurement tools, learning packages,

improvement of recipes, and research and development.

Thailand is currently in the final stages of finalizing the

SALTS action plan under the 2016 sodium reduction

policy11

. In response to increasing evidence on sodium

consumption exceeding recommended levels35

and

trends in consumption of frozen and ready-to-eat-

meals36,37

, the policy has set targets to reduce salt

consumption by 30% over the next 8 years in line with

WHO global targets for 2025. A 3% yearly reduction in

urine sample measurements to ensure progress with set

targets will be incorporated within the next Thai

National Health Examination Survey38

.

A national Low-Salt Network38

, established to support

current policy initiatives, has brought together over 40

experts and concerned agencies across government,

academic, and civil society sectors. The stakeholder

group is instrumental for initiating activities around

promotion of policies, public health awareness, and

knowledge creation for the purpose of encouraging

gradual and measurable reductions in packaged and

restaurant/street food.

The 2016 government Notification of Mandatory

Nutrition Labeling and GDA amounts13

– including

sodium content – in snacks, chocolate, bakery products,

semi-processed foods, and chilled/frozen read-to-eat

meals, paved the way for the development of an official

health logo14

for consumers. Since the launch of the

front-of-pack Healthier Choice Logo, new standards are

available for 6 food groups, including instant noodles5,34

and porridge39

– rated among the highest products in salt

content on the market. 51 food companies have joined. A

total of 232 products have been reformulated, including

182 beverages, 8 seasoning sauces, 36 dairy products, 3

instant noodles, and 3 snacks40

. Other plans and

considerations are underway concerning expanded food

labeling relating to nutrient function claims, maximum

4

levels, enforcement of new nutritional labeling

expectations, and official lowering of Thai RDI upper

limits from 2,400mg to 2,000mg41

.

Other food sources, particularly those in institutions and

street food, have remained largely unregulated42

. These

sources contribute significant amounts towards total

energy intake43

. Future initiatives to develop a shop

rating score are included within the strategy. Pilot

projects are also ongoing in environments such as

hospitals that have developed Healthy Menu options18

.

The technology and innovation prong of the strategy

seeks to develop further research in order to support

implementation of programs. Limited number of studies

have been conducted on knowledge, attitudes, and

perspectives of Thais. Of the studies found, behavioral

assessments examined the dietary habits of hypertensive

patients22

and the habits of college students5.

All studies found indicated that Thai adults consumed

over tolerable intake level amounts24,28,50

. Thai children,

apart from consuming foods high in sugar content, also

consumed foods high in sodium28,44

. Thailand aims to cut

national sodium intake by 30% by addressing the main

drivers responsible for high consumption rates in the

population.

I. Ongoing Research Ongoing research studies were also identified. Current

research studies ranged from assessments of sodium

content in 7/11 processed/packaged foods and other

market data, to investigations in usage trends of the

mobile Food Choice phone application, and

developments of potassium chloride based salt

substitutes utilizing umami ingredients. In addition,

recently concluded research pertaining to sodium

reduction through reading labels, sodium screening

devices in food and urine samples, and evaluations of

national trainings on GDA and salt education were also

found38

. Food science research conducted in leading

universities are exploring Thai herbs and spices as

potential salt enhancers, potassium chloride (KCI) salt

substitutes, and the use of umami (savory taste)

ingredients as taste improvers within potassium chloride-

based salt substitutes.

Interview Themes

A. BARRIERS

Perceived barriers obtained from participants were

diverse and associated with the sector that the

stakeholder was located within (Table 2). All

stakeholders interviewed were supportive of salt

reduction. Some barriers dominated stakeholder and

expert concerns in 5 main areas (Table 3).

I. Prioritization of Interventions and Leadership Monitoring and evaluation activities, according to

stakeholders and experts, were ambiguous, which

limited the scope of the strategy. It was unclear how the

actionable items under the strategy would be periodically

measured, and how data collection would help inform

future projects to strengthen the strategy. Lack of clarity

in the concrete ways to implement the strategy was a

chief reason why dispersed projects on sodium reduction

were disconnected, according to stakeholders. Pilot

projects across all sectors were perceived to each be

overseen by its own siloed department – a clear

coordinating mechanism linking each project to a central

overseeing agency, absent.

II. Inter and Intra Agency Collaboration

Although the government was acknowledged for

bringing together many key stakeholders involved in the

areas of salt and sodium reduction, it was observed that

stakeholders were disconnected and lacking synergy.

This played a major role as to why some stakeholders

could not clearly observe the national impact of the

strategy.

III. Marketing and Health Promotion Current capability to reach the population through

segmented messaging, especially higher-risk groups, was

identified as ineffective by the majority of stakeholders

and experts. Lack of cohesive community-based sodium

reduction and health promotion interventions were

identified. Conflicting or unclear messaging, particularly

with product labeling, hindered consumer ability to

make informed decisions.

IV. Industry Approach and Timing Stakeholders identified obstacles to developing

innovative strategies that engage industry through soft

power tactics for obtaining a higher degree of buy-in

from companies. In their perspective, legal mechanisms

and enforcement, identified as ‘hard power’ strategies

required complimentary approaches that considered

industry concerns regarding reformulation, technical

assistance, and timing for meeting targets gradually.

Other stakeholders perceived industry innovation and

consumer health as divergent, with a weak link among

the two.

V. Research Priorities

A general lack of research in the dimensions of sodium,

consumer acceptance, cost effectiveness, and long term

health impacts was also identified as a barrier for

evidence based decision making. Other stakeholders

indicated a low level of national support and priority for

projects investigating food behavior, food psychology,

and nutrition.

5

B. RECOMMENDATIONS

Recommendations emerged from discussions on the

ways to address perceived barriers in 4 main areas.

I. Monitoring and evaluation

Monitoring and evaluation, and promotion of a

continuous iterative process that evaluates the

effectiveness of current initiatives, was key for many

stakeholders. Stakeholders and experts conveyed the

importance of ensuring that resources and synergies

were maximized and interventions were well suited for

the population. Developing centralized mechanisms that

monitored progress for the country was suggested.

II. Policy and Strategy

Stakeholders recommended strengthening the

stakeholder network – particularly through public/private

cooperation and long-lasting partnerships with other

ministries – and connecting the strategy to other

initiatives such as the NCD strategy, and tobacco/alcohol

strategies. Many stakeholders recognized the importance

of legal policies and enforcement of mandatory

regulations. As a complement, many advised additional

focus on street food and food that was not yet nationally

regulated. Differing opinions on tax measures, maximum

levels of sodium in products, and other legal measures

for sodium reductions were designated as ongoing topics

in the field.

III. Consumer education and behavior modification

Most national stakeholders and experts highly rated

consumer education and environmental change as most

effective potential drivers for altering consumption

behaviors. They advised additional focus on programmes

and initiatives that targeted households, communities,

children, the open environment, and food shops. The

topic of creating healthier environments with access to

healthier food options across all populations and

geographical regions was a theme that dominated

discussions. Interventions that provided trainings to

provincial health personnel and educational resources for

teachers and children – as techniques to uplift

communities – were also suggested.

IV. Research

Continued research on the diverse facets of food and

nutrition including food psychology, assessments on

future gradual reductions and their impact on technical

requirements from industry, and investigations on

consumers’ taste and acceptance over time were

suggested. Research in tandem with long-term,

continuous mass awareness campaigns were implied.

Most stakeholders and experts agreed that standardized

measurement of current initiatives – in order to gauge

current successes of rolled out efforts – would be useful

knowledge to aid in developments of future innovative

interventions.

Summary and Conclusions This report scans available literature on the topic of salt

reduction in Thailand, assesses the perspectives of

national stakeholders and experts on barriers to salt

reduction policy implementation and provides

recommendations.

The data verify that current levels are around double that

of global recommended levels, and that the major

sources come from condiments used in the household,

packaged foods, and food bought from street vendors.

Perspectives from national stakeholders and experts

highlight a strong collective commitment to supporting

the SALTS strategy and curbing sodium consumption

rates in the Thai population. Stakeholder reports of the

perceived barriers in prioritization of interventions and

leadership, stakeholder collaboration, marketing and

health promotion, industry approach and timing, and

research priorities illustrated strategic areas for policy

improvements. Centralized monitoring and evaluation

efforts, focusing the policy and strategy, strengthening

consumer education and behavior modification

initiatives, and research development are specific

recommendations from national stakeholders that

promote optimal performance and impact of the salt

reduction policy.

Thailand is taking key steps to fulfill its commitment to

reducing sodium intake for improving population health.

This study pointed to institutionalizing sodium

surveillance – for purposes of monitoring and measuring

the national impact of the actionable items under the

strategy – and the role of a collective stakeholder

network in focusing the strategy and promoting gradual

and achievable results toward set targets.

Word Count: 2,820

6

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8

TABLE 1: Recent research studies that measure sodium intake and/or dietary sources of sodium in Thailand (n=8)

*Research not yet published.

Study Name Author(s) Date Group/Age Sampling Measurement Results URINARY SODIUM

EXCRETION METHOD

Situation of Sodium/salt Intake

in Thai Population21

Dr. Luechai S.; Maj.

Thanita W.; Thanida A.;

….

2012

2,226

aged 15-59

200 subsample

National;

Convenience; Cross-sectional

24hUNa; 24-hour-

dietary-recall;

response rate: 67.8%

Median 2,955.5 mg/day ; 87.5% level of >

2,300 mg/ day; 4 persons have level exceeding 4,600 mg/day; 22.6% ate instant noodles >

3x/week

Prevalence of High Sodium

Intake among Hypertensive

Patients at Hypertension

Clinic, Siriraj Hospital22

P, Buranakitjaroen;

M.Phoojaroenchanachai

2013

320

hypertensive

patients

Cross-sectional

24hUNa

Mean total daily Na intake 3,404 mg/day i.e.

3.4 g of Na/day; prevalence of high salt intake

at 73.4%; 76.3% patients who knew effects of

salt on BP consumed high salt diet

Daily salt intake estimated by

overnight urine collections

indicates a high cardiovascular

disease risk in Thailand23

Hirohide Yokokawa,

Motoyuki Yuasa,

Supalert Nedsuwan

2016

793

participants at

high risk of

CVD

Cross-sectional;

cluster

randomized

trial

24-hour salt intake

estimated from 3 days

overnight UNa

Mean salt intake 3,960 mg/day; higher salt

group patients with family history of HTN,

antihypertensive drug use, less ideal BMI,

higher exercise frequency, lower intake

awareness

Study on the effect of low

sodium condiments on blood

pressure and sodium intake in

hypertensive patients in the

community*25

Dr. Surasak

Kantachuvetsiri

....

2016

100

hypertensive

patients

Community-based

participatory

research; cross

over RCT

12h overnight UNa;

Blood pressure (BP)

Mean 4,000mg/day; use of low sodium condiment in household cannot reduce daily

BP/sodium intake per day; intensive education

can reduce salt intake/BP

DIET RECALL MEHOD

Study of Sodium Chloride

(NaCI) Consumption Among

Thai People26

Ministry of Public

Health, Bureau of

Nutrition

2009

2,733

households

National ;

Multistage

random

7-day -dietary-recall

Mean 4,320 mg/day (10.8g/salt/day)

Sodium Intake and Socio-

Demographic Determinants of

the Non-Compliance with

Daily Sodium Intake

Recommendations: Thai

NHES IV27

Warapone S. Rachada

K.; Surasak T.

2011

8,462 (aged 2-

14); 20,470

(aged 15+)

2,969 subgroup

Data sampled

from National

Health Exam

Survey

(NHES IV)

Food frequency

questionnaire;

24-hour-dietary-recall

Daily consumption of snack foods increased to

42.9%; 10% eat instant noodles daily

2,472.7 mg/day for those 1-15 years; 3,264.5

mg/day for those 16 years and older

Global, regional and national

sodium intakes in 1990 and

2010 …9

John Powles, Saman

Fahimi, Renata Micha,

Shahab Khatibzadeh …

2013

-

-

Age-standardized

estimated sodium

intakes

Average sodium 5,400 mg/day (13.5g/salt)

The Intake of Energy and

Selected Nutrients by Thai

Urban Sedentary Workers:

Evaluation of Adherence to

Dietary Recommendations29

Katiya I, Jeeranun K.,

Rewadee C., Chukiat V., Wanicha K.

2014

215 adults 20–

50 years in sedentary

occupations

Convenience

24-hour dietary recall;

2-day food record;

response rate: 78%

male; 73% female

Male median intake 1,967 mg/day; female

intake 2,021 mg/day

9

TABLE 2: Participating Stakeholders Areas of Interest, Position, Concerns and Strengths (n=15)

Sectors Area of Interest Position Concerns Strengths & Opportunities

Public

Ministry of Public Health

Department Agencies

Other autonomous state

health agencies

Developing,

implementing innovative

policy to reduce NCDs

Coordinating, endorsing,

funding innovative

projects

Supportive; wants

centralized government

approach and local policy

initiatives

Supportive; wants to

support hard/soft power

initiatives that balance

stakeholder interests

Private sector role,

lobbyists, siloed

departments; lack of strong

community-level

nutritional policy

Coordination; audience

segmentation; monitoring

and evaluation; how to

most effectively engage

industry (i.e. soft power)

and government (i.e. hard

power)

Can negotiate with industry; develop data

management, infrastructure, financing,

consumers’ knowledge base, evaluation

(KPI); can regulate street food/restaurants;

can expand policy (regional, provincial,

district, community, family, individual)

Knowledge in innovation and strategies

for practical implementation; can advocate

for a more holistic approach to salt

strategy that can link to national agendas;

can motivate/educate individuals; bridge

different sectors

Private

International/ national

companies, industry

associations

Public awareness,

informed consumers,

demand

Supportive; wants to see

increased public/private

partnership

Challenging targets,

collaboration, time, product

acceptability, strategy

reaching local

communities; too many

decentralizes pilot projects

Increased public/private collaboration can

have greater impact; knows consumer;

have more capacity to make change within

communities since they are closer to them;

they sponsor local events

Civil Society

NGOs, nonprofits, social

networks

Professionals, food

associations, academic

institutions

Developing mass

awareness campaigns to

educate the public;

bridging all sectors;

driving strategy forward

Development of food

science research and

nutrition field

Supportive; wants to see

additional government

impetus

Supportive; wants to see

increased national support

for health research and its

potential impact

Coordination and

collaboration; linking all

sectors; scaling up effective

programs; funding for new

innovations; slow moving

government

Current funding trends,

people’s evolving behavior;

lack of qualitative studies

to support quantitative

research; timing for

product reformulation

Can maximize use of communication

strategies resources and networks to

disseminate information to communities

locally; can influence consumer demand;

can educate on hidden sodium sources in

food (i.e. MSG)

Can turn young researchers into

champions; can advocate for more

university projects to be scaled up and

implemented nationally; can encourage

prioritization of food psychology, food

science, nutrition, behavior change

10

TABLE 3: Barriers to and Recommendations for Successful Implementation of the SALTS Strategy Thailand, 2017

Themes Identified

Barriers

Prioritization of Interventions and Leadership � Not enough emphasis on consumer education and behavior change

� The action plan is relatively new– though roles are defined, it is not unclear who will lead & coordinate implementation

� Ambiguity with the M&E Framework; population surveillance inconsistent and no follow up NaCl survey since 2009

� Fragmentation of actions and pilot projects divided among different sectors; lack of overseeing body

� Too much emphasis on reformulation and regulatory mechanisms despite 80% of food consumed at home/street/market

� Rigidity of government which usually depends on internal leader within govt. sector to champion a project

� Weaknesses in labeling and marketing: Healthier Choice Logo, monochrome labeling

� Difficulty of WHO sodium consumption guidelines to be practically implemented despite political will

� Lack of low-salt products available broadly

� Top-down approach is not effective especially for poorer, rural communities

Inter and Intra Agency Collaboration

� Perceived disconnect among the stakeholder network – disparate and lack of synergy – cannot clearly see impact on national level

� MoPH departments are understaffed and underfunded, and at times working in isolation without clear connecting mechanism with

other stakeholders and ministries, especially those relating to the food chain

� Weak integration of salt policy within larger systems (NCD, veggie, fruit consumption, tobacco)

� Lack of effective inter-ministerial partnerships

� Lack of government leadership willing to implement proven interventions and/or scale up pilot programs

Marketing and Health Promotion

� Ineffective at reaching target segment populations (children, elderly, NCD patients, adolescents)

� Unclear and confusing for the consumer

� Not strong enough to work against misinformed social media information and/or industry

Industry Approach and Timing

� There is a weak link between Industry innovation/technology and consumer health

� Lack of inventive strategies for obtaining higher degree of industry buy-in through soft power methods

� Industry cannot adapt to 30% reduction immediately and requires time for gradual adjustment

Research Priorities

� Lack of research on salt, sodium, reformulation, and food science for informing policy and interventions

� Insufficient research on consumer acceptance, value, cost effectiveness, and long term health impacts

Recommendations

Monitoring and Evaluation

� More investment in M&E related to evaluating current interventions & integration with other NCD risk factors and data systems

� Establishment of a consumer database to measure consumption behavior trends of products with healthier choice logo

Policy and Strategy

� Strengthen stakeholder network; additional assistance to meet targets set out by MoPH/FDA

� Expand strategy to link with national agenda beyond MoPH

� Clear designation of a centralized implementation body and systematic evaluation framework

� More rigorous and consistent population surveillance

� More emphasis on other initiatives: tax (similar to sugar tax), warning labels (similar to tobacco), upper limits of sodium in food,

traffic light approach (in order to expand number of products), a more practical approach that accommodates sodium reduction levels

with the product type/category; expansion of labeling to all packaged foods; additional focus on national street food initiatives

� Harmonization of national guidelines and data collection methods/management

� Ongoing/continuing collaboration with industry and private sector, public/private partnerships

� Development of long-term, sustainable approach for collaborating with other ministries/extending beyond health-related agencies

Consumer Education and Behavior Modification

� Prioritization of consumer education across all population segments especially children, elderly and other high risk groups

� Prioritization on educating street vendors

� Utilize nutritional teachers and/or train teachers in nutritional education

� Develop creative, culturally relevant inexpensive tactics that focus on behavior modification

� Emphasis on educating consumer on using informed choice (GDA) as a tool rather than providing consumer with an interpretive

symbol (Healthy Choice logo)

Research

� More investment in food science research, nutrition, behavior modification, food psychology, consumer behavior

� More investment in sodium molecular research, monosodium glutamine, sodium chloride

11

FIGURE 1:

FIGURE 2:

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FIGURE 3:

FIGURE 4: