Thai salt reduction strategies

Strategies for Sodium Reduction for NCDs and CKD Prevention in Thailand Assoc. Prof. Surasak Kantachuvesiri MD, PhD Renal Division, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Chairman of Thai Low Salt Network, Nephrology Society of Thailand

The Low Salt Network (LSN) was launched in October 2012 • Nephrology Society of Thailand (NST) has launched a low salt campaign on world kidney day in March 2010 • NCD net under International Health Promotion Foundation (IHPP) called the interdisciplinary group meeting on sodium reduction in 2012 including academia and Min. of Public Health (MoPH) • Royal College of Physicians of Thailand (RCPT) joined the network and LSN was established at the RCPT. • Thai Health Promotion Foundation provided funding. • We started from 2 prongs 1. Public communication 2. Research for policy advocacy 2

Example of Research Projects Food reformulation in Thai Research Team dishes Institute of Food Research and Development of Salt meter Product Development, Kasetsart University Food database and salt content Faculty of Engineering, Mahidol Survey of salt in package food University Hospital and Communities Institute of Nutrition, Mahidol campaign University Thai FDA and Kidney Patients Association Low salt network and NCD Division, Dept. of Disease Control, MoPH 3

The steps to establish the network • The leader is respected and trusted by the public • Recruited all sectors of society • Divide tasks according to their aptitude and ability. • Creative and open-minded • Brainstorm and find the best strategic action • Good communication within and outside the network • Public communication across all channels and opportunity • Monitor progress 4

How LSN gained momentum? • We got support/training from the Thai Health Promotion Foundation for Public communication • The central administrative team includes the chairman, secretary, researcher, communication, and finance personnel. • Many groups conduct a research/model for policy advocacy eg. Food Labeling/ legislation on taxation. • All projects set the KPIs in order to achieve a major goal of the network • Annual budget initially came from Thai Health to the LSN and then subcontract to each research group. • Regular meetings and brainstorm 5

Who support it? Financial: Thai Health Promotion, Resolve to save lives, WHO CCS-NCD, Thai Kidney Foundation, National Health Service, Nephrology Society of Thailand Technical: WHO, Better Health Program, UK. The George Institute, AU IHPP, HITAP of Thailand, Mahidol university, Kasetsart University Civil Society: Nephrology Society, Nephrology Nurses Association, Kidney Patients Association, Consumer Protection foundation. Dietician Society, etc. 6

National Health Assembly endorsed national policy to reduce salt intake in 2015

Thai National Strategies for Sodium Reduction 2016-2025 (Adoption from WHO guideline)

Five Strategies S = Surveillance A = Awareness L = Legislation and environmental reform T = Technology and innovation S = Scaling up stakeholder network 11

0 500 1,000 1,500 2,000 2,500 3,000 2,804 3,500 3,249 5,000 4,500 4,000 แกงเขียวหวาน 2,147 2,566 แกงเทโพ แพนงหมู 1,424 2,746 ฉูฉี่ปลาทู 2,443 4,472 แกงสม้ ผกั รวม แกงเลียง 1,154 2,639 2,328 ตม้ ยา/ตม้ โคลง้ แกงไตปลา 1,950 แกงจืดวนุ้ เสน้ 2,420 2,871 แกงจืดมะระ 2,135 1,709 ไข่พะโล้ 1,520 1,487 2,066 ตอ่ หนว่ ยขาย ปลาทูตม้ เคม็ ผดั เผด็ ปลาดุก 1,125 1,586 ปลาทอดราดพริก 1,246 1,898 2,529 ผดั วุน้ เสน้ 2,342 ผดั ผกั รวม 2,107 ผดั พริกขงิ ถวั่ ฝกั ยาว ผดั กระเพราไก/่ หมู หน่อไมผ้ ดั พริกหมู/ไก่ กุนเชียง หมูทอดกระเทยี ม… ปลาทอด น้ าพริ กกะปิ น้ าพริ กปลารา้ น้ าพริ กอ่อง หลนเตา้ เจี๋ยว/ปู 13

The First Nationally Representative Population-based Survey in Thailand using 24-hour urine collection methodology J Clin Hypertens. 2021;23:744–754. 14

Mean Sodium Intake 1.8 times the recommendation Characteristics Total Mean (95% CI) P value (N) Overall 1,599 3,635.6 3450.6-3820.7 - Region 164 3,495.9 <0.001 324 3,759.7 3495.9-3495.9 0.086 Bangkok 332 3,562.7 3490.4-4029 342 3,315.8 3244.3-3881 Central 437 4,107.8 3171.5-3460 3990.5-4225.1 North 373 3,797.4 436 3,792.6 - North East 454 3,616.2 3437.2-4157.5 336 3506.9-4078.4 South 3224.4-4007.9 Age groups 18-29 years 30-44 years above 45-59 years 3,294.1 2949.8-3638.4 60 years and J Clin Hypertension: 2021 Apr;23(4):744-754 15

Higher sodium consumption was independently associated with • Younger age (Adjusted Odds Ratio (AOR) 2.81; 95% Confidence interval (CI): 1.53-5.17; p= 0.001); • Higher education (AOR 1.79; 95% CI: 1.19-2.67; p=0.005) • BMI ≥25 (AOR 1.55; 95% CI: 1.09-2.21; p=.016) • Hypertension (AOR 1.58; 95% CI: 1.02-2.44; p=0.038). J Clin Hypertension: 2021 Apr;23(4):744-754

Public Campaign: Spot TV & Education Program 17

Project Media 2.1 Sodium lesstaurant : https://www.sodiumlesstaurant.com/ 2.2 TV program : ลดเคม็ เลือกได้ Less salt you can choose

Project Media 2.3 Short Flims 2.4 Mini quiz game : https://sodiumquiz.lowsaltthai.com

World Kidney Day & low salt week

Campaign Material

Low Sodium Menu

Less salt spoon & Less sauce spoon 23

Less Salt Condiments ตวั อย่าง ผลติ ภัณฑ์สูตร ลดโซเดยี ม

Less salt Pickled Fish

83 Low Salt Hospitals under MOPH 26

Low Salt Community INTERVENTION ❶ Education Education about risk of high sodium intake, ❷Reformulation type of sodium, nutrition ingredients ❸Environmental change ❹Salt meter Dietary recommendation in low sodium intake Encourage about low sodium intake in community Salt meter 27

Thai Salt Meter for monitoring salt content CHEM METER 28

The use of a salt meter helps to reduce sodium intake and BP J Clin Hypertens. 2021;1–10.

LESS SALT COMMUNITIY INVESTIGATOR MEETING

COMMUNITY INTERVENTION PRESS RELEASE BY LOCAL NCD TEAM 31

ตวั อยา่ ง สคร. 2 ลงพนื้ ทก่ี ับชุมชนเครือข่ายจงั หวดั เพชรบรู ณ์ 32

2 Raise people awareness 7-15 Feb 2022 1 3

Environmental change in Public campaign April 22 4 street vendor and publics

PEOPLE IMPRESSION ON SALT REDUCTION PROGRAM AND SALT METER MONITORING No more Now I remember headaches which vendor and high BP after joining provides less salt the program menu 35

LESS SALT COMMUNITIES Area: Northern and Northeastern parts of Thailand 50 pilot areas 36



Reformulation in Package food

High salt products in the supermarket Numbers of high sodium (Na) products Categories Recommended Numbers of high Na (mg/serving) Na products Meal (N=89) 600 74 (83.2%) Snacks(N=2,241) 100 1,088 (48.6%) Drinks (N=817) 100 158 (19.3%) 39

Low salt network, FDA and WHO asked industry to voluntarily reform and gave healthier logo in 2017 % of less salt noodle varies between company Trend of sodium up and down in different food categories 44.4% ท่ีมา : กรม คร. IHPP และอย. ท่มี า : Nielsen Retail Index Instant Noodle 2019

Percentage of healthier products, 2018–2021, by Instant food characteristics. (*p-value<0.05) CHANATIP CHAILEK et al, M.P.S Fac. of Grad. Studies, Mahidol

Policy 1 Salt taxation Policy 2 Maximum Sodium limit and warning labels WHO global sodium benchmarks for different food categories Instant Noodle

Salt tax policy in Thailand •In 2021, the excise department indicated the food products that will be the first target products of the tax are: 1) instant noodles 2) frozen food 3) snacks 4) sauces Slide from Asst.Prof. Sitaporn Youngkong, PhD As of 10 Mar 2022 Faculty of Pharmacy, Mahidol University 43

Salt tax policy in Thailand • In 2020, the Excise Department nominated the draft of salt tax criteria to the advisory committee on NCDs on 27 March 2020 for consideration. • Draft of salt tax criteria: for instant food THB/10 g. Sodium (mg/10 g) Year 2020-2022 2022-2024 2024-2026 2026 onwards  170 0000 170 - 240 0 0 X2 X3 240 - 300 X1 X2 X3 X5 300 - 360 X2 X3 X5 X6 > 360 X4 X6 X7 X8 • This draft proposed a ladder tax rate based on the amSoouurcnet: Noaftiosnoadl Hiueamlth iFnoutnhdaetiopnrwoedbupacgte. Nevertheless, there is no any results from this movement yet. Slide from Asst.Prof. Sitaporn Youngkong, PhD As of 10 Mar 2022 Faculty of Pharmacy, Mahidol University 44

The network proposed salt taxation to the minister of finance in November 2021 45

Next Steps • Public hearing on sodium tax • Media advocacy and social media campaign • Set maximum level and warning labels on high sodium products • Expand the network of low salt hospitals and communities • Procurement policy in the organization • Source of sodium in food 46

Acknowledgement • Dr. Worawan Chailimpatamontree • All staff of Neph. Soc. Of Thailand • All staff of Thai Low Salt Network • National health service office • National Service Plan, Min. of Public health • Thai health promotion foundation • Thai Kidney Foundation • Dietician society of Thailand • Renal nurse association of Thailand • All members of CKD clinic team 47

BIG IMAGE - THANK YOU - 48