Non-communicable diseases (NCDs) mainly consist of cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, and are the most frequent causes of death worldwide. A 2018 World Health Organization (WHO) fact sheet on NCDs notes that 41 million people die annually from NCDs (71% of global deaths), including 15 million people who die before the age of 70.
Of the total deaths in Thailand every year, 60% are from NCDs, principally hypertension, cardiovascular diseases, kidney disease, and so on. Many of these deaths are caused by unhygienic food intake, not exercising, smoking, or drinking, which are public health problems that the WHO and the Thai government are working to resolve and prevent.
Research conducted by the Kidney Foundation of Thailand found that of the 7 million patients with kidney disease found at an early stage, most could be treated by prescribing medication and recommending changes in eating habits to reduce salt intake, thus preventing kidney disease from increasing in severity. In the adult group, up to 17% were found to have early-stage kidney disease but did not know about it or did not experience symptoms of the disease. If patients in such cases do not see a doctor or undergo health checkups regularly, the symptoms will deteriorate until kidney failure. Because people have two kidneys, if one kidney has any problems, with a 50% loss of function, the patients will not exhibit symptoms as the healthier kidney can still perform waste disposal and blood filtering functions as normal. If the problem continues unabated until a 70% loss of function is reached, the patient will begin to exhibit symptoms of kidney failure, which requires dialysis.
The WHO was relatively early to recognize the importance of solving this problem. An awareness campaign advised the public of the danger of the consumption of high-sodium foods leading to various diseases later on, and the WHO is aiming to reduce hypertension worldwide. The WHO requested the cooperation of member countries, asking them to participate in this targeted campaign and encourage local populations to consume no more than five grams of salt per person per day, or no more than 2,000 mg of sodium, in order to reduce the prevalence of chronic diseases. They also set out strategies for the following actions to reduce sodium intake in the population.
- Product reformulation
- Consumer awareness and education campaigns
- Environmental changes
Finland was the first country to start reducing salt consumption in 1978. The country issued regulations requiring warnings to be displayed on the labels of products that have a high sodium content, together with communicating to consumers, by any media, the dangers of high sodium intake, and promoting the use of reduced-sodium salt for cooking. This policy has been successful. The Finnish population reduced its average daily sodium intake from 5,600 mg per capita in 1970 to 3,200 mg in 2002.
The United Kingdom has used the strategy of affixing easy-to-understand nutrition labels to food products with the cooperation of producers in the food industry. This initiative is controlled by the Food Standards Agency, which set up the Consensus Action on Salt and Health (CASH) project. The UK population reduced its average daily sodium intake from 3,800 mg per capita in 2004 to 3,400 mg in 2008.
The United States government has long supported the campaign to reduce sodium, going back to 1980. However, the U.S. population has not changed its salt consumption habits.
Other countries (e.g., Australia, Canada, France, Japan, Malaysia, Singapore, and South Korea) also have campaigns to reduce salt intake in their populations.
t the meeting of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU) No. 31 in Germany in November 2009, the committee agreed that sodium should be the first nutrient to be limited in its Nutrient Reference Value, which is 2,000 mg following the WHO recommendation.
For Thailand’s part, Thai government agencies have agreed to cooperate in solving this global issue. Along with campaigns for Thais to realize the importance of the ingredients they take in when consuming food, there are mobilization efforts for the private sector to turn its attention to food so that consumers get less sodium in their daily diets. There has also been an increase in radio, television, billboard, and online advertising about the benefits of limiting sodium consumption. In addition, the government has encouraged public health personnel at all levels to advise the public about reducing their sodium intake, and in October 2018, the Thai FDA changed the Thai recommended daily intake (Thai RDI) of sodium from 2,400 mg to 2,000 mg, following WHO and CCNFSDU recommendations.
The Department of Disease Control of the Ministry of Public Health launched “SALTS,” its strategy for reducing salt and sodium consumption in Thailand (2016–2025), in October 2016. It comprises the following initiatives:
S: Stakeholder network. Establishing, developing, and expanding partnerships.
A: Awareness. Increasing knowledge, awareness and skills among the public, communities, producers/entrepreneurs, relevant professional personnel, and policy makers.
L: Legislation and environmental reform. Environmental changes for the production and improvement of current products until low-sodium options increase in the market and the public has access to food with low-sodium content.
T: Technology and innovation. Research and knowledge development, leading to the implementation of practical solutions.
S: Surveillance, monitoring, and evaluation. Development of surveillance, monitoring, and evaluation systems, focusing on the entire process, output, and results.
In April 2016, the Thai Food and Drug Administration (Thai FDA) issued regulations regarding required nutrition labeling and guideline daily amounts (GDA), including GDA labeling for bakery products, biscuits, chocolates, cookies, popcorn, semi-processed foods, snacks, and wafers (e.g., instant noodles, boiled rice, and congee). A GDA-compliant label is an easy-to-read nutrition label displaying the GDA of the ingredients. It contains information about energy, sodium, sugar, and fat values of the entire product and the serving recommendation for daily intake. Also in 2016, the Thai FDA created a “healthier choice” logo to provide a quick visual image to assist consumers in decision-making for more balanced nutrition. Product manufacturers and importers that wish to affix the logo to a product must seek permission to do so from the Nutrition Promotion Foundation under the Institute of Nutrition of Mahidol University, which assesses nutritional values carefully in determining whether to grant permission.
With the cooperation of several government agencies (e.g., the Thai FDA, Consumer Protection Board Office, Department of Disease Control, Department of Health, and others) and private parties (e.g., Thai Health Promotion Foundation, Federation of Thai Industries, Kidney Foundation of Thailand, Foundation for Consumers, and others) the Less Salt Network campaign was created to reduce sodium consumption in Thailand by setting targets for reducing salt intake by one, two, and three grams by 2016, 2019, and 2022, respectively. By 2025, the campaign aims for people to consume not more than seven grams of salt per person per day, or no more than 2,000 mg of sodium per day.
The Less Salt Network and related parties have made a strong effort to persuade food companies in Thailand to reduce salt and sodium additives in food, and several food companies are following the campaign and have agreed to reformulate their products. However, many companies are not yet on board and refuse to cooperate. Therefore, the government’s voluntary sodium-reduction target, expected to be implemented by the food industry, has not yet been achieved. The government will continue to explore other strategies for salt reduction in Thailand.
Salt is not the only culprit that contributes to NCDs. Sugar must also take a portion of the blame, especially in respect of diabetes and obesity. To combat this, Thailand launched a sugar tax on October 1, 2019, as a strategy to reduce people’s sugar intake, which many consider to be the likely model for the future imposition of a similar salt tax. Studies of the impact of a salt tax in Hungary show that such measures can be effective at changing consumers’ eating habits. According to the WHO data, in Hungary, the introduction of a tax on certain foods with very high salt content caused people to turn to less salty food that is not subject to the salt tax.
The Thai government is thus aiming to set up a salt tax in the coming years. The priority target product is instant noodles, and other products will be included in future phases. However, such a tax is just one available tool, and even after it comes into effect, government agencies and other private parties will still need to find other ways to influence consumers into eating healthier alternatives and to support sustainable consumption habits.