Tuesday, May 7, 2013

A Critique on Restricting Salt Intake Initiative - Shruti Sachdeva

The occurrence of Cardio-Vascular diseases is one of the most challenging issues for the public health in current times. According to Centre of Disease Control (CDC) “Heart diseases are the leading cause of death in USA. Every year 600,000 people die of heart disease in the United States.”[1] Very recently excessive salt intake has also been associated with auto-immune diseases in mice, thus could have potential effects in humans as well.[2, 3] Aside from its humane cost, there is considerable financial cost attached with occurrence of these diseases. Every year 108.9 billion USD are spent for health care of heart patients.[1] The problem is complicated as there are no few and deterministic reasons responsible for occurrence of heart diseases. Amongst the many factors, excessive intake of salt has been identified as playing significant role in heart diseases. Recent studies have shown that excessive salt intake may result into raised blood pressure, adverse cardiovascular health and child obesity.[4-8] However, salt is an essential everyday item, a key component for cooking food and hence the ideas of government intervention for salt consumption evoke strong responses.
While governments in some states and also at federal level have taken steps in promoting health awareness and/or restricting the salt consumption among people[9], this issue however has been lingering in the academic and health circles for a long time. Studying the effect of food on behavior and health of human body has been core area of research. In this domain, the research points strongly that currently; the average salt intake by American citizens is much more than the required intake for healthy functioning. A recent study in Journal of American College of Cardiology shows that reduction of salt intake by 1200 mg daily across the population could lead to 60,000-120,000 lesser heart related problems and healthcare savings of $10-$24 billion each year.[8] So salt intake restriction has been proposed, considering that a part explanation of the prevailing health crisis in increased cardio-vascular problems and increased obesity across the nation is attributed to excessive salt intake.[4-8] It was proposed that businesses are responsible in nature and they were ready to abide to their duties.[9] Some states have already accepted the regime of ‘National Salt Reduction Initiative’. It is considered as a public health issue and it is believed that a ban or limitation of salt as ingredient of food in restaurants and pre-packaged foods may decrease the risk of heart disease.[10, 11] To this regards, I will discuss an intervention, provide arguments as to why it is not effective, and propose more effective solutions.
 ‘National Salt Reduction Initiative’
The central argument of researchers studying effect of salt on human health is that everything including salt should be consumed in just the right proportions. The advocates argue that amount of salt is already too high in most food items served in the market to begin with. Further the food served in restaurants comes pre-loaded with salt and does not consider consumers preferences in amount of salt they are comfortable with. One such advocate, NYC Health Commissioner Dr. Thomas Farley says, "Consumers can always add salt to food, but they can't take it out”. As an intervention NYC department of Health and Mental Hygiene came up with an idea of National Salt Reduction Initiative. It (NSRI) is a partnership of more than 90 state and local health authorities and national health organizations. Its demeanor is to set unforced limits for regulation of salt levels in 62 categories of packaged food and 25 categories of restaurant food. Some well-known food products already withstand in a good shape with these suggested.[12, 13] 
1st Criticism of Intervention: The intervention does not solve its Susceptibility or Vulnerability problem
To start with, the proposed salt intake reduction may appear misguided. It is true that through NSRI food companies and Restaurants may agree to reduce the salt content of prepackaged and restaurant food in the acceptable limits. As daily safe salt intake is estimated to be 1,500mg as compared to American daily intake at present that is 3,600 mg per day, it is really challenging to cut 40% out of their diets at a single stretch. Food companies and restaurants may agree to decrease salt quantity in food they serve, but is it feasible to expect that people may not add further salt themselves and thus eat 40% less salt in their diets?
Firstly, occurrence of heart diseases cannot be attributed to a single reason such as salt intake and there are various risk factors like Body Mass Index, life-style, genetics, behavioral factors and sodium intake etc. Behavioral factors (unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol) alone accounts for 80% risks of coronary heart disease and cerebrovascular disease.[14] Thus if reducing incidences of coronary diseases is an aim, the initiative fails in acknowledging the role of other factors. Even after regulating the amount of salt in prepackaged food and other restaurant food, people are still vulnerable to heart diseases. Salt ban is not stopping anyone from eating empty calories or living a sedentary life style.
Secondly, there are many loopholes in this regulation. It does not regulate the salt on table top of every in house dinning nor does it regulate the purchase of other sodium stuffed pre-packaged food that does not fall under this initiative by the state government. If someone develops the perception of vulnerability, no one can stop him or her to stuff themselves with donuts and cheesy burgers or becoming an obese couch potato.
And the third vulnerability is associated with perceptivity of the problem. According to Health Belief Model, perceived susceptibility or vulnerability refers to one's perception of the risks or the chances of contracting a health disease or condition.[15, 16] If people develop a perception that by reducing salt intake is the key and the only factor to combat heart diseases, they may become lax towards other factors. By imposing a restriction on salt in restaurant foods, people may become more casual about the intake of the salt in their homes and thus this lack of information may be equally responsible to be one of the factors contributing to coronary diseases.

2nd Criticism of Intervention: It invokes psychological reactance among people
Psychological reactance is an aversive affective reaction in response to regulations or impositions that impinge on freedom and autonomy.[17, 18] Essentially when people are restricted or told not to subject themselves in doing certain activities, they in fact choose to do the exact opposite of what is told to them.[18]  
Because salt is such a widely used ingredient and essential part of everyday food, a restriction on its usage evokes strong emotional response among population. Already, a main argument by the opponents on the salt restriction has been that it encroaches upon personal freedoms and liberties of people.[19-21] In such environment, the opponents have been successful in large extent in branding the ‘reduction in salt initiative’ as a ‘ban on salt’ altogether. As such, people view this as an effort by few individuals and especially the government to dictate how people should live their lives. As a result, a large section of population behaves against such restrictions in opposite because they feel that there is a need for them to show that it is ‘they who control their own lives and not the government.’ This rebellious aspect is a motivating factor for them to restore their freedoms that they think are under attack. Thus instead of taking a control over their diet, people in fact come do the opposite and consume salt in even greater quantities.
Further, opponents of salt intake restriction have latched on to new ‘health’ arguments in railing people against restrictions thus sowing seeds of mistrust amongst their minds. Even the opponents use the ‘health’ argument by pointing that sodium is an essential ingredient for healthy living and it is the lack of salt that can lead to health crises and that there is a lack of proof on adverse effects of salt.[10, 22-24] They also claim that there is a steady misinformation campaign by the government and the harmful health effects are overblown.[22] Indeed such mistrusts fuel the resentment amongst population who feel that they are being guided like ‘sheep’ and this evokes even stronger rebellious intent against such measures.
And indeed evidences have recently been shown the ‘boomerang effect’ may be playing a bigger role against restricting salt intakes. According to Victor Fulgoni, PhD, Senior Vice President of Nutrition Impact, LLC, a food and nutrition consulting company “Research shows us that despite public health efforts to decrease sodium intake, actual intake has continued to increase over the last 10 years and solutions to help decrease dietary intake are greatly needed.”[25]
3rd Criticism of Intervention: It fails to use social cognitive theory
Social Cognitive theory posits that people may be able to self-regulate by experiencing an outcome themselves or by following examples of others.[26] According to Prof. A. Bandura, the founder of Social Cognitive Theory, the core determinants include ‘knowledge’ of health risks, perceived ‘self-efficacy’ that one can self-regulate one’s behavior, ‘perceived facilitators’ that increase one’s determination to overcome obstacles, and ‘outcome expectations’ about benefits that may come from adopting different health lifestyle.[26] The salt restriction initiative is misguided in the ‘knowledge’ sense of the theory. The problem of salt reduction is grander in scale, but by introducing the reduction in restaurant food the initiative has reduced it to a simple one dimensional problem. The daily eating habits of people are complicated and the average number of times people dine outside in a week is much less than the total number of meals in a week. Additionally, the restriction is effective in very narrow domains. Eg. people may order a pizza using home delivery, and while the pizza maker may reduce the salt intake in the pizza, there is nothing that stops a customer from adding salt on his own once the pizza has been delivered to him/her. The initiative assumes that people will gain the ‘knowledge’ aspect themselves over period of time through such salt reduction practices by restaurants and there is nothing in it to adequately impart such knowledge amongst consumers.  
Further, impositions of laws that aim to change the health lifestyle behavior are perceived as inability of people to guide themselves into what is best for themselves. In case of NSRI, such interventions also accompanied by putting a ‘fine’ on the restaurants that do not abide by the rule. Such enforcements are deemed as punishments without any obvious reward by the masses. Human nature is that we do not want to be imposed of wills of others, and punishing behavior does build more grudges against such measures as compared to reinforcement that could be done either via teaching or by exemplifying lives of others who have tried those changes themselves and willingly and had outcomes that changed their lives and can be used to inspire others.
New Intervention Proposal: Building a nexus between government, industry and health insurance industry to reach consumers
For an intervention to be successful on a national scale, several things need to be done remove inhibitions and concerns amongst people. Government must realize the concerns of citizens and to alleviate them, it must build a robust architecture to address them involving food industry, consumers and the health insurance industry. Dr Amanda Jenkins, author of one of the studies answers that by saying ‘With the studies now clearly indicating that excessive salt intake does affect the body in significant ways, it is time for government and industries to join hands and find a solution to counter this problem.’
A new intervention that aims to spread knowledge amongst consumers while also rewarding consumers who show a change in lifestyle related with sodium intake will be widely useful in achieving the aim of decreasing coronary diseases and other associated problems due to excessive salt intake. The first part of such intervention would aim in spreading the message through use of conventional and social media. The main goal of such intervention is to dispel the rumors and uncertainties about the Laws related with salt reduction, as well as making people understand about the harmful effects of excessive salt intake. The second part of the intervention would involve be that health advocates need to team up with hospitals and doctors, and spread the message to the visiting patients. And in the third part of the intervention, the existing health insurance architecture may be used to reward the consumers who show an improvement in their sodium intake.
Local governments may give funding to social groups that aim in promoting the health benefits of normal salt intake on conventional media and social media. Example of promotions may include food items with pictures of equivalent amount of sodium in them. Further, images and videos can be prepared that show the adverse effects of salt intake.
Healthy families may be interviewed, and questions related with their dietary practices may be recorded with special emphasis on how they control the salt intake. And such videos can be used as positive reinforcement mechanisms to ‘nudge’ people into self-regulating salt intake in their diets. Then, the government may urge doctors to spread the message specifically through the doctor-patient network. Doctors may be requested to urge patients to control their dietary habits and extol the benefits of controlled salt intake habits. Because the patient-doctor relation is exclusive with no intermediaries, patients are likely to hear and accept a doctor’s advice on matters related with health. Finally, the government can seek greater role of healthcare insurance industry in promoting healthcare. Eg. in case of car insurance, the drivers see a reward of good driving habits when their car insurance goes down after a period of safe usage without any driving violation. Similarly, the insurance companies may institute a reward program where patients that have high sodium intake may see some decrease in their health insurance if their blood sodium levels meet normal range.
Defense of New Intervention 1: Using media to promote message and addressing Susceptibility or Vulnerability problem as laid in 1st critique
As stated in Critique 1, the present intervention technique has perceived susceptibilities. Such vulnerabilities can however be handled using the proposed new intervention with aid of media messaging.[27]
Media-Agenda setting theory explains that media has a profound influence in shaping public opinion and policy. According to Deegan and Brown, “higher levels of media attention (as determined by a review of a number of print media newspapers and journals) are significantly associated with higher levels.”[27] Such increased cognizance among the public is in fact related with any issue that media may choose to highlight. Thus media does not only deliver the news, it can shape a message. This feature of the media can be rightfully used to promote the message of limiting salt intake amongst public. Example, advertisements can be made that highlight that the rightful purpose of salt reduction is promotion of good health among public. In this regards, athletes and sportsperson from a community may be roped in for advertisements, as they usually have high dietary standards and are generally healthy. This would especially be useful because such individuals are generally considered in high regards amongst the public and their opinions may make significant impression among the public. Using such individuals in advertisements, the governments and health organizations may use them as aid for dispelling rumors about the proposed laws for salt reduction, emphasizing that such initiatives do not comprise of ‘banning’ them or reducing the liberties of individuals.
Although most packaged food sources have labels informing use of salt in them, advertisements can be made that include food items with pictures of equivalent amount of sodium in them. Videos can be used where for example a material is exposed to excessive salt solution and as a result, the material shows degradation. Such videos can be disseminated using social media websites such as youtube, vimeo etc.
Further, effective use of Social Cognitive theory can help in promoting the message of controlled salt intake and self-efficacy amongst the public. Healthy families may be interviewed, and questions related with their dietary practices may be recorded with special emphasis on how they control the salt intake. When people would see video recordings and interviews of individuals who are just like them, they will be able to relate themselves with the people in videos. This would serve as positive reinforcement mechanism. Especially stories of people who have undergone transformation due to regulating their salt intake may specially be very effective. Individual stories where they suffered from coronary diseases or obesity, and then decided to change their lifestyles and hence saw marked improvement in their health can act as great inspirational narratives for others to follow.
Defense of New Intervention 2: Using doctor-patient relation to promote healthcare
As part of new intervention, along with celebrities, using hospital-patient networks can reinforce the messaging of salt intake effects on health. Typically hospitals carry pamphlets on many diseases and healthcare problems. Salt intake is usually not found amongst the list of healthcare problems that are usually discussed this way. By adding specific pamphlets and brochures that discuss salt intake and its effect on human body may raise significant awareness among population. Such pamphlets may comprise of short stories of individuals indicating their daily diet and occurrence of coronary diseases that was attributed to excessive sodium in their blood.
Further, doctors may actively use such knowledge dissemination techniques while they are having a one-to-one correspondence with the patient and if the patient blood reports suggest high sodium activity. The personal nature of the interaction in such cases can have profound effect on behavior of patients. Indeed if the messenger is a trusted physician, people are less prone to use psychological reactance towards the message. The doctors may themselves be incentivized if the patient shows an improvement in their sodium intake in future rounds of blood diagnostics.
Defense of New Intervention 3: Using reward based mechanism and addressing ineffective use of social cognitive theory as laid in 3rd critique
Amongst all the debate on salt reduction, one aspect that has hitherto not been breached is the role that healthcare insurers themselves can play in promoting good health. Although this may be a controversial idea and needs deeper study before it could be considered for implementation, similar mechanisms are already in place in other domains, the most prominent being in the car insurance industry. The car insurance industry acknowledges the good driving behavior of individuals by rewarding them occasionally with perks such as decreased car insurance in case of a sizeable period of safe usage involving no driving violation. A program like this would address aspects of Social Cognitive theory where individuals may also be rewarded for their behavior and self-efficacy is promoted because they have an incentive to improvise their health state.[27]
Taking cue from this behavior, the health insurance industry can offer similar incentives to the ‘erring’ individuals. The health insurers usually have the history of health of individuals. Individuals that have high sodium content in their blood in reported incidences may be given an incentive such as they can be promised a decrease in their insurance by a percentage or a dollar amount if the next 2 or N number of blood diagnostics show a decreased amount of sodium intake. This type of intervention is also suggested to likely give a positive outcome based on ‘Theory of reciprocity’.[28] Eg. patients that come to a doctor or hospital usually undergo a number of diagnostic treatments. For patients that have high BMI or have cardio-vascular problems, their sodium intake may be monitored. If high levels of sodium are found in the blood levels of individuals, then the health insurer may send them a note informing them that they have been identified amongst people with risk towards cardio-vascular diseases. And if in next 2 or N number of exams (chosen by an insurance company after a detailed study), the individuals show a marked improvement in the identified sodium content in their blood, the insurance company may reward them by a decreased value of insurance.
Evidences as published in research articles show that excessive salt intake is associated with a number of health ailments and the society will benefit tremendously if its usage is brought down. The National Salt Reduction Initiative is an admiral attempt by the government and does a good job in giving a national recognizance to a subject that deserves this prominence. However the means and the methods that have been employed in the initiative to achieve the outcome ignores a number of important insights from social and behavioral perspective. It promotes rebellion amongst people and promotes a sense that government aims in all around control over the personal liberties of individuals. Since the ultimate aim is the benefit of the public, the government should choose an intervention where it recognizes the fears of general public and allays them with the right type of messaging using the power of media. An intervention where the doctors and health insurers are also inclusive to the messaging may have a better chance of succeeding.

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