Salt Reduction Initiative of the Pan American Forum for Action on NCDs

Transcription

1 Salt Reduction Initiative of the Pan American Forum for Action on NCDs Report for the Third Meeting of the SaltSmart Consortium October, 2014 WHO/PAHO Office, Brasilia, Brazil 1

2 Table of Contents Executive Summary 1 I. Background... 3 II. Welcome and Agenda... 4 III. Brazil Highlights... 5 IV. Progress with Salt/Sodium Reduction Targets and Other Initiatives... 7 Dietary salt reduction in Barbados... 7 Proposal for a regulation to implement Chile s "Law 20,606 on nutritional composition and advertising of foods" and Chile s voluntary sodium reduction strategy... 8 Costa Rica s progress with targets and other initiatives... 8 Consumers International your rights, our mission... 9 Healthy Caribbean Coalition... 9 American Heart Association Sodium Reduction Initiative International Food and Beverage Alliance V. Advancing Harmonization with Regional Targets The Concept Note on Target Harmonization Principles to Guide Target Harmonization the Consensus Statement Proposed Regional Targets VI. Consortium Roles and Contributions in Target Dissemination, Maintenance and Monitoring.. 15 VII. Summary of Agreements and Actions to Advance Target Harmonization VIII. Next Steps APPENDIX 1: Concept Note on Target Harmonization APPENDIX 2: List of Participants at the Third Meeting of the SaltSmart Consortium APPENDIX 3: Meeting Agenda

3 Executive Summary Consistent with the SaltSmart Consortium s Strategic Plan that priorized harmonization of salt/sodium reduction targets for the Region, the Concept Note on agreeing on harmonized regional targets for salt/sodium concentration in key food categories in the Americas, was prepared as preparatory part of 3 rd meeting. The Note proposed regional targets (maximum values) for nine key food categories and a process for the Consortium to agree to, maintain and monitor the targets. The Draft Consensus Statement was also prepared to outline a set of principles to guide the Consortium members in their working together on the proposed process. Using the Concept Note as the basis for discussion, at the Brasilia meeting, Consortium members were able to achieve the following objectives to advance regional harmonization of targets: Consortium consensus on principles to guide how it can agree on, maintain and monitor regional targets Consortium agreement on proposed regional targets for key food categories Consortium identification of roles and contributions of each sector represented in the Consortium in adopting, disseminating and monitoring regional targets, and how to support country capacity building to adopt regional targets or set unique national targets The following are the actions agreed to by Consortium members to advance with target harmonization: Action on the Consensus Statement The Consortium accepted the principles in the Consensus Statement. A small working group will adjust the Statement based on discussions and will circulate the new version as soon as possible. Action on Regional Targets The Consortium accepted the premise on which the regional targets are based and the proposed values. The sub-group will add a category for condiments and sauces; identify definitions for the food categories; and highlight the lower value from the range of existing targets for each food category. Action on Disseminating Regional Targets Each Consortium member will disseminate the regional targets through their channels. PAFNCDs will circulate the regional targets with the Policy Statement to governments in the 1

4 Region, and will work with Consortium members to compile where the targets have been disseminated. Action on Monitoring Adherence to Regional Targets PAFNCDs will approach sub-regional food technology institutions and relevant WHO collaborating centres to explore capacity and willingness to collect label data from industry to serve a regional initiative. NGOs will approach the George Institute about extending the training for its iphone app. The food industry representatives agreed to supply label data to a central database. Action on Resource Mobilization A sub-group of the Consortium will prepare a funding proposal for nutrition label monitoring. Participating will be Hubert Linders (CI), Adrianna Blanco (Costa Rica), Mary L Abbé (Canada), Maisha Hutton (Healthy Caribbean Coalition), Eduardo Nilson (MOH Brazil) and Maria Roza Rabanal (IFBA Latin America). The basis for the proposal will be how by using a food switch mobile application, the baseline salt/sodium concentrations for the key food categories can be determined from food labels and how the values will be reassessed in two years. With additional impetus from the American Heart Association, the Consortium also agreed to advance further with social marketing: Action on Social Marketing A sub-group of the Consortium will prepare a proposal for the next full Consortium meeting that is to articulate a way forward for social marketing. Participants will be Diana McGhie (AHA), Maisha Hutton (HCC), Elizabeth Vargas (UNILEVER), Hasan Hutchinson (Health Canada), the PAHO/WHO Collaborating Centre at the University of South Florida and the PAHO secretariat. 2

5 I. Background The global target of 30% relative reduction in salt/sodium intake is a means by which the populations of WHO Member States can reach the recommended intake level of <2000mg sodium per day. For the Americas Region, WHO/PAHO encourages achievement of the recommended intake by As of December 2013, there were formal national initiatives to reduce the overconsumption of salt/sodium in 11 countries in the Americas Argentina, Barbados, Brazil, Canada, Chile, Columbia, Costa Rica, Ecuador, Mexico, Paraguay and Uruguay plus the National Salt Reduction Initiative (NSRI) in the US, an entity outside the national government. Eight have targets and timelines for reduced salt/sodium in specified food categories: Brazil, Canada, Mexico and the NSRI have exclusively voluntary targets; Argentina, Chile and Ecuador have both voluntary and regulated components to their approaches (the regulations require warning labels on packaged products that exceed upper limits for critical nutrients including sodium); and Paraguay has regulated the salt content of bread. The SaltSmart Consortium in its Strategic Plan agreed to advance the harmonization of targets and timelines for reducing salt/sodium content within common food groups; and to promote and implement reformulations to reduce the salt/sodium content in a group of agreed-upon products, leveraging existing national and industry efforts. The Consortium recognizes that harmonization will leverage the multisectoral efforts directed at dietary salt reduction in the Region, benefitting national strategies to improve the quality of the food supply and food industry product processing: countries without targets can take advantage of the targets and timelines already in place and the lessons learned; consumers across the Region will be in a better position to achieve the recommended intake and the associated health gains; and food companies can migrate to harmonized formulations for same-products supplied to markets in the Americas. To proceed with regional target harmonization, a sub-group of the Consortium looked into five countries in the Region where initiatives with target and timeline setting are the most advanced as of the fall of 2014 Argentina, Brazil, Canada, Chile and the NSRI. The experiences in these countries supply the evidence that salt/sodium reduction targets are feasible and acceptable. Each of the initiatives identified food categories specific to the roles of salt/sodium in formulations and established targets with timelines to reduce the use of salt/sodium through negotiations between public health authorities and food industries, assisted by independent food technology experts and in some cases with inputs of consumers. A key lesson taken from the most advanced countries is that targets that are maximum values (upper limits) for salt/sodium concentrations in food products are the most straightforward concept 3

6 with which governments, consumers and the food industry can work. An important finding was that a number of broad food categories that contribute substantive amounts of salt/sodium to the diet are common to all the countries. The sub-group combined these two aspects into a Concept Note on agreeing on harmonized regional targets for salt/sodium concentration in key food categories in the Americas. The Note had proposed regional targets (maximum values) for nine key food categories and a process for the Consortium to agree to, maintain and monitor the targets. The sub-group also prepared a Consensus Statement to confirm a set of principles to guide the Consortium members in their working together on the proposed process. Using the Concept Note as the basis for discussion, with this meeting, the Consortium was to achieve the following objectives to advance regional harmonization of targets: Consortium consensus on principles to guide how it can agree on, maintain and monitor regional targets Consortium agreement on proposed regional targets for key food categories Consortium identification of roles and contributions of each sector represented in the Consortium in adopting, disseminating and monitoring regional targets, and how to support country capacity building to adopt regional targets or set unique national targets The meeting also provided an opportunity for countries, civil society organizations and food industry representatives to give updates on national target setting and other relevant initiatives, and to respond to the proposal for regional targets. This report briefly outlines the presentations made during the meeting and summarizes the discussions that followed. It concludes with actions that Consortium members agreed to to advance with target harmonization and outlines next steps with another Consortium objective regional social marketing. Complete presentations are posted on the PAHO website at 323&lang=en II. Welcome and Agenda Zohra Abaakouk, Coordinator for Social Determinants of Health, Health Risks, NCDs & Mental Health in the PAHO office in Brazil, welcomed participants. She acknowledged the importance of the Consortium s work in mobilizing multiple sectors towards the common goal of dietary salt/sodium reduction. She stressed its important contribution to the prevention and control of diet-related noncommunicable diseases. 4

7 Patricia Jaime, Coordinator for Food and Nutrition in the Brazilian Ministry of Health greeted participants on behalf of the Government of Brazil. Brazil has already demonstrated reductions in salt/sodium content in selected food groups and reached the 2015 targets. The success underpins Brazil s new nutrition guidelines. Branka Legetic welcomed participants on behalf of the WHO/PAHO and PAFNCDs and reviewed progress with regional dietary salt reduction. In the first phase of the initiative, the Expert Group supporting it produced several technical documents now compiled in Salt-Smart Americas a guide to country-level action ( Now in its second phase, the dietary salt reduction initiative in the Americas is focusing on implementation. WHO/PAHO and the Technical Advisory Group (TAG) that now advises the initiative are supporting three levels of countries: those most advanced that have multiple food categories with targets and timelines; countries taking preliminary steps with single food categories, the most common being bread; and countries that anticipate taking action. In 2012, the SaltSmart Consortium was established on the PAFNCDs platform and produced a Strategic Plan. At its first meeting, the Consortium priorized two of the Plan objectives: social marketing and regional target harmonization, areas with existing capacity. At its subsequent meeting, it explored a social marketing process. This third meeting of the Consortium is strategic. It is a significant opportunity in that the targets and timelines in five of the most advanced countries in the Region amount to a critical mass of evidence of the salt content reductions that are technically feasible and acceptable to consumers. Guided by the TAG, the Consortium using the PAFNCDs platform mechanisms is in the position to agree to a set of regional targets for key food categories based on targets that already exist and to disseminate them across the Region. To this end, during this meeting Consortium members will consider a Concept Note on target harmonization and a Consensus Statement on a course of action. III. Brazil Highlights Brazil s second edition of dietary guidelines (2014) Patricia Jaime The underpinning for Brazil s latest dietary guidelines is that health is a basic human right warranting support and protection, and by extension healthy diet is based on broader concepts of food security and intersectoral health promotion. Unlike other national food guides, Brazil s guidelines are based on evidence that people are changing their eating patterns and as such, its key messages emphasize behaviour: Make foods and freshly prepared dishes and meals the basis of the diet. 5

8 Be sure oils, fats, sugar and salt are used in moderation in culinary preparations. Limit the intake of ready-to-consume products and avoid those that are ultra-processed. Discussion How will Brazil change its approach to nutrition surveillance to correspond to the new guidelines? To date, monitoring food consumption has involved population and administrative surveys and nutrition surveillance. There will be a change in surveillance processes to capture the guideline s emphasis on behaviours e.g. new indicators will be markers specific to the eating patterns and consumption of ultra-processed foods. Brazil NCD Action Plan Eduardo Nilson representing Deborah Malta The Brazilian government is committed to an NCD Action Plan with an intersectoral approach, having engaged approximately 20 government ministries in its elaboration plus NGOs, universities, civil society and the private sector. The key risk factors being addressed are tobacco use, harmful use of alcohol, unhealthy diets and physical inactivity, and action areas are prevention and health promotion, integral care and surveillance, monitoring and evaluation. Partnerships for health promotion are based on voluntary agreements between health authorities and e.g. food industries to reduce dietary salt intake and the media on campaigns to prevent smoking and encourage fish consumption. Brazil has also advanced with laws on tobacco and alcohol control and anticipates the same approach regarding e.g. food marketing, tax incentives for healthy foods and disincentives for unhealthy foods. Priorities with health care are access to free medicines, prevention of cervical and breast cancer, urgent care and primary health care. The next step is involving partners in monitoring and evaluation. Brazil s progress with food reformulation and monitoring of results Eduardo Nilson Monitoring whether biannual sodium reduction targets have been met has involved checking food labels, conducting laboratory analysis of product samples and following the use of sodium-based ingredients by food industries. Findings are that there have been reductions not only in the upper limits of sodium content in food products but also in the average sodium levels of products. The food companies that have signed agreements have influenced the whole market in that companies that have not signed agreements have also reduced their sodium use. New targets are now needed for some of the categories to achieve further reductions. There is continued monitoring of targets for 2012 and 2013 and of population impacts through surveys. 6

9 Discussion How does Brazil deal with food companies that do not achieve the targets? Given that Brazil s targets are voluntary, in cases where a food company does not achieve them, public health authorities will initiate communications to discuss obstacles and work with the company on a plan to reach the national targets. An underlying incentive for food companies to respect voluntary targets is the understanding that authorities are willing to consider fiscal or legal measures to ensure that targets are met. What mechanisms and structures are supporting Brazil is its multisectoral approach? Brazil s culture of democratic engagement and public consultations is underpinning its progress. Councils are one mechanism that brings together multiple sectors e.g. one convened on malnutrition and hunger has evolved to deal with NCDs and micronutrients. There are also interministerial chambers; the one for food and nutrition security is responsible for an intersectoral strategy on obesity. A challenge with the multisectoral mechanisms is monitoring the performance of non-health sectors towards a health objective. Indicators are evolving e.g. adding teaching of health status as an indicator in education. IV. Progress with Salt/Sodium Reduction Targets and Other Initiatives Three countries presented updates, responding to three prompts: Have main sources of salt/sodium in the diet been identified in your country population? Have food groups for reformulation been selected? Is there a monitoring system for following changes in salt/sodium in food? Dietary salt reduction in Barbados Trevor Hassell The final report for the Barbados Sodium Intake Survey is expected before the end of Its principle aim was to determine a baseline mean intake of dietary sodium in adults using 24-hour urine sampling. Its secondary aim is to identify the main sources of dietary sodium in the diet. Regarding NCDs, civil society is involved in preparing national/regional status reports to inform a call for action on NCDs in the Caribbean community. There is indication of possible funding support for specific programmes for blood pressure control and population dietary salt reduction in seven Caribbean countries. 7

10 Proposal for a regulation to implement Chile s "Law 20,606 on nutritional composition and advertising of foods" and Chile s voluntary sodium reduction strategy Luisa Kipreos The public discussions on Chile s new law are finalized. The law sets upper limits for sodium, sugars, fats and calories per serving of selected liquid and solid food products, and requires front-of-pack warnings when limits are exceeded. With Chileans experiencing transitions in lifestyles and nutrition, the new law intends to assist consumers in understanding the nutrient and caloric profiles of the food products they are purchasing and give food companies incentive to reformulate. With bread, the basis for the now regulated sodium content was the reductions that bakeries achieved voluntarily. For other key sources of sodium in the diet, in particular processed meats and cheeses, the sectors are not well organized (compared to the bread sector) and responses to voluntary targets have been weak. The new law is allowing 24 months for product reformulations after which warning labels will be required if limits are exceeded. Costa Rica s progress with targets and other initiatives Adrianna Blanco-Metzler Costa Rica has used national household budget surveys to track the main sources of salt in the diet; the next survey is expected in and will include collection of 24-hour urine samples to confirm sodium intake. The most recent survey has shown that a primary source of salt in the diet is condiments that are added during home cooking. While health authorities made local producers of condiments aware of the issue at preliminary meetings, a number of obstacles to reformulation were identified: baseline data on sodium content are not consistently available as nutrition labeling is not mandatory; there are no current targets to guide reformulations for condiments; and even if targets were available, small and medium enterprises (SME) in the sector indicate that they lack the capacity to reformulate. Since 2012, Costa Rica has been part of an international project coordinated by the George Institute in Australia that involves countries around the world collecting food label data for the most common global-brand products and submitting them to a central database. These data represent a baseline for sodium content (and other nutrients) for these products in each participating country and allows comparison of products between countries. Data from more than 5000 labels have been collected to date In Costa Rica. Subsequent data collection for the same products will capture changes in the nutrient profiles. 8

11 Three civil society organizations presented updates, responding to three prompts: How is your organization supporting salt/sodium reduction activities in the region? What is the capacity and interest of your organization to support dissemination of regional targets? Does your organization have the ability to support monitoring of regional target implementation e.g. collect label data? Consumers International your rights, our mission Hubert Linders CI is promoting a framework convention on unhealthy food control similar to the FCTC, with the goal of making healthy foods accessible to all consumers. Specific to dietary salt/sodium reduction, CI for Latin America working with PAHO has set up ALASS (Acción Latino-Americana de Sal y Salud), the regional counterpart of WASH that provides information for consumers and professionals in Spanish. CI is working on strengthening and consolidating ALASS as a network. One feature is an interactive map with countries in the Region showing advances in salt/sodium reduction through legislation, voluntary agreements, industry efforts and civil society findings. It is anticipated that CI members and other civil society groups will undertake the monitoring activities proposed in the Concept Note on target harmonization. Needed are protocols, capacity building and resources. Healthy Caribbean Coalition Maisha Hutton HCC is supporting salt reduction activities in the Caribbean through: ongoing education e.g. publishing a weekly newsletter, posting on HCC social media and other member websites; and supporting the annual WASH activities, the Barbados Sodium Intake Survey and the PAFNCDs SaltSmart Consortium since its inception. HCC will also be supporting the planned civil society salt reduction initiative to involve seven Caribbean countries. HCC has the interest and capacity to support dissemination of regional targets; as to supporting the monitoring of uptake of regional targets by e.g. collecting label data, HCC has the interest but not the capacity. 9

12 American Heart Association Sodium Reduction Initiative Diana Vaca McGhie AHA has three strategic priorities to reduce sodium intake at the population level: support federal sodium targets; increase consumer demand; and coordinate scientific responses. Specific to its consumer campaign, objectives are to increase awareness, inspire behaviour change and build an audience of supporters. AHA is promoting life s simple 7 to achieve its 2020 Impact Goal a 20% improvement in health status relative to seven risk factors (one of which is healthy diet); and improving cardiovascular health by 20% while reducing deaths from CVD and stroke by 20%. Sodium intake of <1500mg/day is a feature in healthy diet. AHA s overarching logo for the 2020 initiative is Life is Why. Food industry representatives responded to three prompts: On 15 September 2014, IFBA renewed its worldwide commitment to health and wellness. How does the commitment apply to salt/sodium reduction in the Americas Region? What would be your organization s contribution to encouraging other food companies and food sectors to adopt regional targets? What would be the role of the food and beverage industry in supporting the monitoring process for regional targets? International Food and Beverage Alliance Maria Roza Rabanal IFBA members made their first collective commitment to the WHO Global Strategy on Diet, Physical Activity and Health (2004) in Members enhanced their commitment to WHO in September 2014 in response to the 2011 UN Political Declaration of the High-level Meeting on the Prevention and Control of NCDs and WHO s Global Action Plan ( ) for NCD prevention and control. Specific to sodium, each IFBA member will be announcing an approach to sodium reduction if applicable to the company s portfolio. To date, one of Mondelez s stated actions has been 10% reduction in sodium in its current food portfolio. Alliance of Food and Beverage Associations in Latin America (ALAIAB) Strategy to Strengthen the Food and Beverage Industry in Latin America Diego Hekimian ALAIAB is a relatively new entity; its board of directors was elected and organizing statutes approved in May Association members are currently in 14 countries. Key objectives are to expand membership and to strengthen the image and positioning of food and beverage industries throughout the Region. The Alliance frames industry respect for voluntary agreements for sodium reduction as consistent with one of its values to contribute to society and governments. Examples are the agreements made by COPAL in Argentina and ABIA in Brazil along with those made by product-specific trade associations in both countries. 10

13 Discussion How will IFBA s renewed worldwide commitment to health and wellness, declared in September 2014, relate to salt/sodium reduction in the Region? By the end of 2014, each IFBA member will make public its specific commitments to improving the nutrient profiles of its food products. Commitments like these need to go beyond IFBA to include small and medium enterprises in as many countries as possible. Monitoring the salt/sodium content of breads from small local bakeries is posing a challenge in Brazil as none of the establishments label their products. How does Chile monitor small bakery breads? To fulfill the requirements of the new regulation, public health authorities have taken samples from artisanal bakeries for analysis. Currently there is capacity for product analysis in the Metropolitan area; the Ministry of Health and the Public Health Institute are working to set up four other centres in the country to analyze samples. Why has Chile set a two-year window for the food industry to complete reformulations? After two years the new law will be enforced. During the two years, public health authorities will be encouraging food sectors as needed to reformulate. What is the extent of the controversy in Central and South America around the science supporting dietary salt reduction? In Brazil, the salt industries represented by the Salt Institute are fuelling the controversy. Brazil is countering with data supplied by e.g. WASH. In North America the food industry is resourcing a continuation of the controversy despite having publicly agreed to voluntary salt/sodium reductions. Food companies must have an internal consistency regarding the issue. How is the AHA working with CDC and the FDA? AHA is promoting a more aggressive target for sodium intake (<1500mg Na/day) than the other institutions. AHA s added value is in its increasing support to consumers and elevating the urgency of salt/sodium reduction policies needed at federal and state levels. What is the capacity of civil society for product monitoring? Food formulations differ depending on the country. In very general terms, countries in the south have less healthy foods than in the north. But no matter the region, civil society organizations can undertake product monitoring e.g. the WASH initiative, by taking advantage 11

14 of available instruments and mechanisms e.g. the George Institute application. Nevertheless they need resources; they have limited capacities. V. Advancing Harmonization with Regional Targets The Concept Note on target harmonization Norm Campbell and Mary L Abbé, WHO/PAHO TAG, Consortium sub-group on target harmonization The Concept Note outlines four steps for the Consortium to advance regional harmonization of targets: confirm the role of regional targets, agree on target values, promote and disseminate them and monitor progress. At this meeting the Consortium is in a position to take the first two steps agree on the role of regional targets, confirmed through a Consensus Statement, and agree on proposed regional target values based on existing targets for common key food categories. For the latter two steps dissemination of regional targets and monitoring their adoption the Consortium will examine the options presented in the Concept Note and decide on how to take these two steps forward. This meeting is an opportunity to build on the initiatives in the Region that are the most advanced with targets and timelines for salt/sodium reduction. Their approaches and experiences have already been distilled in the Guide for Setting Targets and Timelines to Reduce the Salt Content of Food, published by PAHO in 2013, directed at countries that intend to set unique national targets. In broader terms, the Guide is to foster collaboration and harmonization of approaches, and support expansion and consistency of targets. The targets that have been agreed to in countries can be further disseminated. Referring to the maximum target values that a number of countries have set for key food categories, this Consortium can by consensus agree to regional harmonized targets maximum values (upper limits) for specific food categories to guide countries that to date have not established their own targets. The starting points for this meeting are therefore a Concept Note on target harmonization setting regional targets; a Consensus Statement that sets out the principles by which the Consortium can agree to, maintain and monitor regional targets; and a table of proposed regional harmonized maximum targets adapted from Appendix 1 in the Guide (Targets and timelines for food categories common in Argentina, Brazil, Canada, Chile and the NSRI (updated in October 2014)). In the table of proposed targets that the Consortium will consider, the food categories selected were identified as major sources of salt/sodium in two or more countries, and maxima targets were preferred from among the target types that the various countries have chosen. Fundamental to 12

15 basing harmonized regional targets on existing targets is that the latter have been set after extensive consultations. Discussion The regional targets proposed are maximum values. Four countries in the Region have maximum values for multiple food categories (Argentina, Brazil, Canada and Chile). Where at least two of the countries have a maximum value for a common food category, the highest value was taken as the regional target. Regional targets, as upper limits, can only influence foods that are outliers at the high end, whose salt/sodium content is higher than the regional target. Maximum values for food categories are more readily understood and accepted than averages or sales-weighted-averages, and between countries, are most readily transferable for common food categories. Regional maxima are a reasonable first step with target harmonization for the Region. The extent of similarity or difference among products in a food category determines whether sub-categories are needed. Definitions for the food categories will be clarified. Principles to Guide Target Harmonization the Consensus Statement Branka Legetic The Consensus Statement has both the principles to guide the Consortium in accepting harmonized regional targets and a call to action. With harmonization in the Consortium s Strategic Plan and with a working version of proposed regional targets in hand, agreement on the principles in the Consensus Statement will move this objective forward. Proposed Regional Targets Mary L Abbé The principles to guide the Consortium s agreement to regional targets are consistent with the principles that countries applied to determine their national targets: Countries priorized food categories that contributed significant amounts to salt/sodium intakes. The proposed food categories for target harmonization are among the categories selected by at least two of the four countries with maximum target values (upper limits). For most of the food categories, the categories are broad and the targets have a relative consistency in the Americas. 13

16 Countries set their targets through extensive consultations, with advice that the targets were technically feasible and that they respected the characteristics and roles of salt/sodium for the food categories. Choosing the highest value from the range of maximum targets to be a regional target for a food category is the least stringent approach to harmonization. - The timeline target year of 2016 is consistent with the proposed two-year approach for review. Discussion Other Regions are taking similar approaches. The EU community has 15 common food categories with maximum values; countries are to choose five categories that are priorities in national contexts. Across the EU, out of the 15 categories, five are most consistently selected. For the Pacific Islands where targets do not exist, maximum values were determined from external sources and will be re-visited over time. Regional targets can be useful to transnational food companies to guide the formulations of same-food portfolios. They can potentially facilitate common market activities related to standardizing food imports and exports. Within countries, because regional targets are maximum values, compliance amongst SME should be easier than with other types of targets. For Paraguay, the regional targets will be useful as guides for national industries and if accepted at MERCOSUR, will make imported products also compliant. Paraguay s legislation on salt/sodium content of bread has already taken effect; bread has been evaluated at 509mg Na/100g, below the proposed regional target. Chile has demonstrated that for bread, 400 mg Na/100g a substantially lower target value than the proposed regional target is also feasible. The lower values in the ranges for the food categories are equally legitimate targets for the categories. Columbia is in the process of setting targets and timelines. The utility of the regional targets is clear there is no need for national targets to be above the highest maximum values already set. Governments and food companies can use the existing targets as reference values. Each of the food categories has a range of maximum targets. The national target for a food category should be less than the highest value in the range but countries can be more ambitious. Regional targets do not preclude countries from setting lower more stringent targets. The lowest values in the ranges are in fact the current optimal targets that governments and food industries should be aiming for. 14

17 For the Caribbean, regional targets are practical, realistic and relevant, and coming from WHO/PAHO, also legitimate. Small countries can be inspired to act when there is action and good examples elsewhere. Agreement on regional targets is a test for the Consortium as they will be useful for the Region. Regional targets are relevant in the context of MERCOSUR, specifically the working group on food and nutrition security that is preparing its action plan. With the key broad food categories having been defined with industry in a number of countries, all based on the role of salt/sodium in formulations, they accommodate the differences in details within a category that may be found in different countries. Selecting the current highest maximum value from the range of maxima to be the regional target for a food category gives governments and the food industry flexibility and confidence to adopt it or a lower target from the range as all the values have been demonstrated as feasible. These initial regional values are a feasible option as national targets for countries that lack data or capacity to establish unique national targets. This way the number of countries in the Region active in reducing salt/sodium intake can grow. As countries gradually achieve their respective maximum targets or the regional targets, the ranges of maximum values for food categories will shift downwards and a new set of lower regional targets can be established. Over time, the benefits of lower salt/sodium intake will be equitably distributed across the Region. A key food category that needs to be addressed and assigned regional targets is condiments and sauces. These are added during home cooking and are an important and increasing source of salt/sodium in Costa Rica and generally in Central America. VI. Consortium Roles and Contributions in Target Dissemination, Maintenance and Monitoring Discussion How best to reach countries without targets? The Guide for Setting Targets and Timelines for Reducing the Salt Content of Food (2013) is the primary resource for countries that intend to determine unique national targets. The regional targets proposed now must nevertheless be disseminated as widely as possible as they are relevant to countries with and without the data and capacity to set unique targets. Regional values should be central in meetings with relevant food industry sectors. 15

18 Civil society can use its networks and community channels to raise awareness of the targets e.g. ALASS accounts for 15 countries in the Region. Regional targets can be supplied first to the associations in ALASS as the norms they are to respect and promote. These associations can then disseminate them further, and the ALASS network itself is expected to grow. Dissemination needs to also reach societies of health professionals. The regional targets should be disseminated to the entities that endorsed the original Policy Statement on salt/sodium reduction and otherwise, should be disseminated along with the Policy Statement as broadly as possible. The PAFNCDs and the Consortium can encourage them to use and/or disseminate them within their respective countries and networks. The Latin American alliance of food and beverage associations (ALAIAB) is prepared to participate in disseminating and monitoring the regional targets among its members. How best to monitor adherence to regional targets? The ALAS website can be a platform for making public the reformulation pledges that food companies make in countries. In Brazil, the government, food industries and civil society are all collecting nutrient profile data. Government laboratories examine label data and ANVISA the health surveillance agency conducts chemical analyses. Government data are considered official as they are based on label information and chemical analyses. The issue at hand is the collection of data in countries that do not have the capacity to collect label information or to chemically analyze food products. Nutrition labels may not be mandatory and laboratory analyses require rigorous methodologies to be reliable. Monitoring must be feasible and sustainable, and account for all the countries in the Region. Baselines for salt/sodium concentrations for the key food categories must be determined now and the concentrations reassessed every two years to check if regional targets are taking hold. The food industry considers label data (+/- allowed margins of error) to be more reliable than data from chemical analyses. Because of a lack of standardization in practices, different laboratories have been found to produce different values for nutrient concentrations. To enforce its law on maximum sodium concentrations per food category, Argentina has designated specific laboratories to conduct analyses of samples for each food category, this way addressing the issue of standardization. 16

19 The food industry can supply label data. Outstanding are selection of independent institution (possibly one of WHO Collaborative centers) that would receive and process the data, the mechanisms for supplying and receiving the data and extent of their analysis. Needed are criteria to select an institution to collect label data using a simple and flexible approach to apply only to the key food categories with regional targets. The institution must be willing to be a partner in piloting a process and have the capacity to scale up. Resources will need to be mobilized. To be explored is an opportunity to apply the George Institute iphone method to more broadly collect brand-label data. A regional initiative to collect data combined with the George Institute project would significantly add value to label data collection on a global scale. 17

20 VII. Summary of Agreements and Actions to Advance Target Harmonization Action on the Consensus Statement The Consortium accepted the principles in the Consensus Statement. Small working group will adjust the Statement based on discussions and will circulate the new version as soon as possible. Action on Regional Targets The Consortium accepted the premise on which the regional targets are based and the proposed values. The working group will add a category for condiments and sauces; identify definitions for the food categories; and highlight the lower value from the range of existing targets for each food category. A new table of targets will be circulated. Action on Disseminating Regional Targets Each Consortium member will disseminate the regional targets through its channels. PAFNCDs will circulate the regional targets with the Policy Statement to governments in the Region, and will work with Consortium members to compile where the targets have been disseminated. Action on Monitoring Adherence to Regional Targets PAFNCDs will approach sub-regional food technology institutions and relevant WHO collaborating centres to explore capacity and willingness to collect label data from industry to serve a regional initiative. NGOs will approach the George Institute about extending the training for its iphone app. The food industry representatives agreed to supply label data to a central database. Action on Resource Mobilization A sub-group of the Consortium will prepare a funding proposal for nutrition label monitoring. Participating will be Hubert Linders (CI), Adrianna Blanco (Costa Rica), Mary L Abbé (Canada), Maisha Hutton (Healthy Caribbean Coalition), Eduardo Nilson (MOH Brazil) and Maria Roza Rabanal (IFBA Latin America). The basis for the proposal will be how baseline salt/sodium concentrations for the key food categories can be determined from food labels and how the values will be 18

21 VIII. Next Steps To Advance Further with Social Marketing Diana McGhie, American Heart Association (AHA) AHA has been testing messages on dietary sodium reduction aimed at consumers. The messages may be adaptable to e.g. the English Caribbean working with the Healthy Caribbean Coalition. AHA s instruments and methods may also inform social marketing initiatives for Central and South American countries. The WHO collaborating centre on social marketing at the University of South Florida will be engaged. Specific formative research will be necessary on which to base a social marketing process. Messages need to be culturally appropriate and aligned to the knowledge, attitudes and behaviours of consumers in defined markets. The Consortium will need to harness the marketing expertise of the food industry. Action on Social Marketing A sub-group of the Consortium will prepare the proposal for the next meeting of the Consortium to articulate a way forward for social marketing. Participants will be Diana McGhie (AHA), Maisha Hutton (HCC), Elizabeth Vargas (UNILEVER), Hasan Hutchinson (Health Canada), the PAHO/WHO Collaborating Centre at the University of South Florida and the PAHO secretariat. 19

22 APPENDIX 1: Concept Note on Target Harmonization Concept Note Agreeing on regional targets for the salt/sodium concentrations in key food categories in the Americas Definitions Key food categories the most common food categories selected for reformulation of salt/sodium content that have been identified in at least two of the five initiatives in the Americas with the most comprehensive reformulation schedules Argentina, Brazil, Canada, Chile and the NSRI. Food category definitions are taken from the Harmonized Commodity Description and Coding System (HS) of the Customs Tariff. Where HS codes do not apply, or if preferred, the category definitions established by countries can be used. Maximum value the upper limit for salt/sodium concentration for a food category or product accepted by public health authorities and food companies to be technologically feasible and acceptable to consumers, yet sufficient to achieve a public health impact Regional target for salt/sodium concentration the highest value for salt/sodium concentration per 100g of food product taken from the range of existing maximum values/upper limits per food category set by countries in the Americas. Where the regional target for a food category has already been met, the lower value in the range of existing maximum targets should become the reformulation target. Background The first Consortium meeting was held in 2012 where members agreed to several main lines of work. At a second meeting, members accepted a Five-year Strategic Plan (2013 to 2018). Of the five objectives in the Plan, they chose to begin with two: social marketing and harmonization of targets. A sub-group of members agreed to work on each of the objectives. Also during the second meeting, members drafted a creative brief for a social marketing campaign. With 12 countries in the Region having initiatives to reduce the overconsumption of salt, and expecting the number to grow, given that salt intake reduction is among the WHO global indicators key to reducing NCDs, it is timely for the Consortium to address target harmonization. The intention is to support the harmonization of targets for food groups common to multiple countries, leveraging on existing national targets in order to support the broader application of such targets throughout the region. Achieving this objective will benefit both national public nutrition initiatives and the food 20

23 industry: countries that intend to set targets for reformulations, but may not have the resources to do so individually, can take advantage of the investments made and lessons learned by others to establish targets and timelines; and food companies can migrate to harmonized formulations for same-products supplied to markets in the Region. PAHO TAG has prepared a Guide to assist countries in setting their own targets. 1 For countries that lack the capacity to do so and to advance the Consortium s objective on harmonization in the Region, TAG has compiled the targets and timelines for nine food categories common in five countries Argentina, Brazil, Canada, Chile and the NSRI. In these countries, food categories for reformulation and targets were agreed upon through negotiations between public health authorities and the food industry, with assistance from independent food technology experts, and in some cases inputs of consumers. 2 What are most feasible to transfer from the five countries above to those that intend to have reformulations are the targets that are maximum salt/sodium concentrations per 100g of food product. Targets based on maxima are not only a straightforward concept for the food industry and consumers, the process of deriving and re-deriving the targets and ongoing monitoring, given the downward shift expected in maxima as reformulations proceed, is more feasible using maxima than averages or sales-weighted averages. The identification of key food categories and corresponding regional targets for them, however, does not preclude countries from deriving sales weighted averages or averages as additional targets for the salt/sodium content of foods nor from setting targets for other food categories or establishing more stringent national targets, either voluntary or mandatory. Regional targets nevertheless will support expansion and consistency of salt/sodium reduction efforts into a broader number of countries, leveraging multisectoral efforts in this area. The process below is proposed to advance the agreeing upon regional targets for key food categories. For each step and its outcomes, there are roles and contributions for each of the sectors represented in the Consortium countries, the food industry, civil society, TAG and PAFNCDs. 1 Guide for setting targets and timelines to reduce the salt content of food, 2013, 2 Targets and timelines for food categories in common in Argentina, Brazil, Canada, Chile and the National Salt Reduction Initiative in the United States, &lang=pt 21

24 Proposed process to agree upon, maintain and monitor regional targets Codes of conduct on transparency, full disclosures and declarations of conflicts of interest will be applied as needed. Step Outcomes Roles and contributions 1) Confirm the role of regional targets in target harmonization in the Region Consortium consensus on principles to guide agreement on and dissemination, maintenance and monitoring of regional targets All Consortium members agree to the Consensus Statement 2) Agree upon regional targets A harmonized maximum value for salt/sodium concentration per key food category or food product as mg Na per 100g for a given year Plan for progressively lower regional targets for the salt/sodium concentration of common staple foods All Consortium members: confirm the key food categories/ products confirm the maximum target per key food category/product identify a schedule for revisiting the regional targets identify options for monitoring adherence to the established targets 3) Promote and disseminate regional targets Consortium members endorse the regional targets as a means to advance harmonization and participate in encouraging uptake by food companies supplying key products in the Region, particularly in markets without national targets PAFNCD circulates the regional targets PAFNCD/PAHO/TAG support countries to build capacities necessary to set regional targets Civil society entities endorse the regional targets and participate in their promotion and monitoring 4) Demonstrate and report on progress towards meeting the targets Publication of food industry pledges to the targets Up-to-date food composition databases Verified label data MONITORING Options for data collection industry voluntarily and regularly provides food composition data on products in the key categories to an independent institution industry voluntarily and regularly provides label data on products in the key categories to an independent institution 22