Stakeholder perspectives on Nigeria’s national sodium reduction program: Lessons for implementation and scale-up

Abstract

Background To reduce excess dietary sodium consumption, Nigeria’s 2019 National Multi-sectoral Action Plan (NMSAP) for the Prevention and Control of Non-communicable Diseases includes policies based on the World Health Organization SHAKE package. Priority actions and strategies include mandatory sodium limits in processed foods, advertising restrictions, mass-media campaigns, school-based interventions, and improved front-of-package labeling. We conducted a formative qualitative evaluation of stakeholders’ knowledge, and potential barriers as well as effective strategies to implement these NMSAP priority actions. Methods From January 2021 to February 2021, key informant interviews (n = 23) and focus group discussions (n = 5) were conducted with regulators, food producers, consumers, food retailers and restaurant managers, academia, and healthcare workers in Nigeria. Building on RE-AIM and the Consolidated Framework for Implementation Research, we conducted directed content qualitative analysis to identify anticipated implementation outcomes, barriers, and facilitators to implementation of the NMSAP sodium reduction priority actions. Results Most stakeholders reported high appropriateness of the NMSAP because excess dietary sodium consumption is common in Nigeria and associated with high hypertension prevalence. Participants identified multiple barriers to adoption and acceptability of implementing the priority actions (e.g., poor population knowledge on the impact of excess salt intake on health, potential profit loss, resistance to change in taste) as well as facilitators to implementation (e.g., learning from favorable existing smoking reduction and advertising strategies). Key strategies to strengthen NMSAP implementation included consumer education, mandatory and improved front-of-package labeling, legislative initiatives to establish maximum sodium content limits in foods and ingredients, strengthening regulation and enforcement of food advertising restrictions, and integrating nutrition education into school curriculum. Conclusion We found that implementation and scale-up of the Nigeria NMSAP priority actions are feasible and will require several implementation strategies ranging from community-focused education to strengthening current and planned regulation and enforcement, and improvement of front-of-package labeling quality, consistency, and use.

Barriers and Facilitators to Dietary Salt Reduction Among Patients With Hypertension in Southern Nigeria: A Hospital-based Qualitative Study

“…Some cultural practices about food and the use of seasoning high in sodium and monosodium glutamate may hinder the adoption of salt reduction. 1 , 35 Increasingly common is the consumption of highly processed foods among hypertensives which was also listed as a common barrier to salt reduction by our participants. 36 …”

“…Excessive salt intake is a major public health concern, particularly in low and middle-income countries (LMICs). 1 , 2 It is a leading risk factor for hypertension and other noncommunicable diseases (NCDs). 3 , 4 Excessive salt intake accounts for 3.2 million deaths globally and 70 million disability-adjusted life years.…”

“… 9 - 12 This exceeds the World Health Organisation (WHO) recommended daily intake of 5 g per day equivalent to 2 g of sodium per day. 1 , 13 , 14 The WHO has set a target of a 30% relative reduction in mean salt intake by 2025. 2 , 15 The Nigerian government has also set a target of reducing salt intake to 3 g per day by 2025.…”

“… 2 , 15 The Nigerian government has also set a target of reducing salt intake to 3 g per day by 2025. 1 This is hoped to be achieved by limiting salt in processed food, restricting the advertisement of food, conducting public health campaigns on healthy diets, and implementing school health programmes on the harmful effects of salt. 1 Major sources of salt intake in Nigeria include discretionary salt (used for household cooking and on the table), seasoning, processed, and ultra-processed food such as bread, meat, dairy and cereal products.…”

Consumption of packaged food and associated factors among adults aged 18–30 years: a cross-sectional study in Kerala

“…Making conscious choice to reduce packaged foods are major contributors to immediate and long-term positive reduction in packaged food consumption (Grunseit et al , 2019). Consumer education, mandatory labeling of packaged food, legislative initiatives to establish upper limit of salt contents in packaged food, advertisement restrictions and integrating nutrition education into school curriculum are some of the key strategies to encourage reduction attempts (Sanuade et al , 2023; Vargas-Garcia et al , 2017).…”