Making a healthy choice on food is pretty difficult when the ingredients are unclear. In New York City there is now a requirement for restaurants to label excessively salty foods. With non-communicable diseases now topping our health challenges and unhealthy diet being a key factor, it is time for a more strident approach internationally.
There are lessons to be learnt from dealing with tobacco. The most important is that information campaigns do not work in isolation. Such campaigns are effective when combined with regulation and accurate, evidence-based information that is readily available and easy to interpret.
More importantly, there are also specific lessons that can be learnt from policies that have been implemented successfully in other countries.
The health star rating system on packaged foods in Australia provides a quick and easily interpreted labelling system that is consumer friendly. Other similar systems, such as traffic light labelling in the United Kingdom, the French nutriscore system or the South American stop sign style warnings help people to make healthy choices.
The cry of “nanny state” echoes loudly any time regulation is mentioned. However, with food marketing completely dominated, the only way for ordinary, busy people to be able to make a considered choice is to have simple, easy information that counters the blanket marketing of some industry players. A free choice is made when accurate information is available. The alternative is nanny industry.
There was an immediate challenge when New York City introduced labelling of high sodium, or “excessively salty” food, in 2015. The National Restaurant Association challenged the city approach of requiring restaurant chains with more than 15 locations nationwide to label any food with over 2300 milligrams of sodium. This is equivalent to around a teaspoon of salt and is the recommended daily limit in the US.
The National Restaurant Association, representing more than 3000 restaurants that came under the regulation, sued New York City claiming that regulation was “arbitrary and capricious”. Nearly four years later the New York Appeals Court accepted the arguments of the Board of Health that they had not “exceeded their authority”.
In marked contrast to the push against science and the “fake news” approach, this type of regulation is now being advanced through a coalition of more than a hundred state and city health authorities known as the National Salt Reduction Initiative. Widespread support includes the Centre for Science in the Public Interest, whose chief executive Michael Jacobson suggests that cutting sodium consumption even in half could “save as many as 100,000 lives per year”.
Australians are not sitting resting on their laurels. Health professionals are aware of the link between sodium and hypertension. The Heart Foundation has been strident in presenting the evidence of the link between sodium and cardiovascular disease. However, the risks to health are much broader. The Cancer Council has a specific policy on salt and cancer risk. This policy aligns with the Australian Dietary Guidelines and, like the US, recommends limiting sodium intake to about a teaspoon a day.
The Cancer Council policy carries a table identifying foods that carry very high sodium content per 100 grams of food. These include stock cubes, oyster sauce, soy sauce, taco seasoning, spam and corned beef. Perhaps more importantly, are the foods that make the highest contribution in the diet including cereal and cereal products along with meat, poultry and game dishes.
The World Health Organisation’s report on the Social Determinants of Health identified the importance of socio-economic frameworks for policy decisions. In a nutshell, the lower the socio-economic standing the less healthy is the population. Fast-food restaurant chains are more abundant in lower-socio economic areas and, therefore, are an appropriate place to tackle the over-use of sodium.
The government’s Food and Health Dialogue is engaging with the food and catering industries to encourage the reduction of sodium in processed and fast foods. This is an important step. However, the lesson from New York City is pretty clear. More can be done! The introduction of appropriate regulation on chain restaurants is likely to have a very significant impact on diet in Australia.
A collaboration of other health groups identified the importance of labelling of salt in food. The collaboration included The George Institute for Global Health, World Action on Salt and Health, World Hypertension League and two World Health Organisation collaborating centres – one on nutrition and the other the Centre for Salt Reduction. The collaboration recommended warning labels similar to those used on tobacco for many years.
An example of such a warning label provided by the collaboration is: “Excess sodium can cause high blood pressure and promote stomach cancer. Limit your use.”
The collaboration identified three potential benefits for appropriate labelling. Firstly, it would increase awareness of the dangers of high-sodium diets by people purchasing sodium and be a reminder of the dangers for people seeing the containers at stores, food service establishments or in the home. Secondly, stores that sell sodium chloride may display sodium less prominently. Thirdly, and most importantly, it could lead to a reduction in sodium consumption.
Saving lives is not a bad goal.
Michael Moore is adjunct professor at the University of Canberra , visiting professor at the University of Technology Sydney, is the former CEO of the Public Health Association of Australia and the immediate-past president of the World Federation of Public Health Associations.