Developing long-term strategies to reduce excess salt consumption in Nigeria

The disease burden attributable to excess sodium consumption in Nigeria, the most populous country in Africa, is large, with 10% of all deaths from cardiovascular disease due to excess dietary sodium.^1–3 While a very wide range of estimates of mean daily dietary sodium intake has been reported among Nigerian adults (dietary sodium range = 2.3–10 g/day; dietary salt range = 5.8–25 g/day),^1,4,5 the Nigerian government estimated that mean salt intake in 2018 was 10 g/day, which is two-fold higher than the World Health Organization (WHO) daily recommendation.⁶ To reduce population-level excess dietary sodium consumption in Nigeria, the country published its National Multi-Sectoral Action Plan for the Prevention and Control of Non-communicable Diseases in 2019, which includes policies based on the WHO SHAKE package. The national sodium reduction programme in Nigeria targets four key policies: (i) mandatory limits of sodium in packaged foods, (ii) mass media campaigns to promote healthy eating, (iii) regulations on food and beverage advertizing to children and adolescents, and (iv) school-based health education programmes. The Nigerian Agency for Food and Drug Administration and Control (NAFDAC) is leading the implementation and scale-up of this national sodium reduction programme along with other national, state, and international agencies based on strategies outlined in the WHO's SHAKE package.⁶ The Nigeria Sodium Study (NaSS) team, which consists of investigators from the University of Abuja (Nigeria), Washington University in St Louis (USA), Northwestern University (USA), and The George Institute for Global Health (Australia) and is sponsored by the National Heart, Lung, and Blood Institute, support, and embed evaluation in this programme's implementation and scale-up. The study team is part of a larger effort co-ordinated by the Global Alliance for Chronic Disease to support late-stage implementation research for scaling up hypertension prevention and control programmes. The NaSS team uses a Type III hybrid, mixed-methods study design through repeated: (i) stakeholder interviews, (ii) populations surveys, and (iii) retail surveys based on the Exploration, Preparation, Implementation, and Sustainment implementation science framework. The goal is to optimize local, regional, and national implementation and to provide generalizable knowledge about implementation strategies to lower dietary salt intake at scale in Nigeria.

The NaSS team has conducted formative research to explore stakeholders’ knowledge and perceptions on the relevant contextual factors that may influence the acceptability, feasibility, and appropriateness of the national sodium reduction programme. In addition, the team has also carried out retail surveys of over 7000 packaged foods in three Nigerian states (Federal Capital Territory Abuja, Kano, and Ogun) to capture novel data through the International Food Switch programme, which was developed by investigators at The George Institute for Global Health and is used in 12 countries. Preliminary analysis showed that the major barriers to the implementation and scale-up of the national sodium reduction programme in Nigeria include customs and cultural taste for high-salted diets, westernization (the adoption of food practices of western Europe), increase in white-collar jobs which have reduced consumption of home-cooked meals (where an individual has control on the amount of salt to add to food), and have increased consumption of out-of-home-cooked foods (e.g. fast foods), and easy accessibility and affordability of high-salted diets. Coupled with this, more than 80% of the packaged foods surveyed have high sodium content with the top five (mg/100 g) being: (i) meat and meat alternatives (904 mg/100 g); (ii) sauces, dressings, spreads, and dips (669 mg/100 g); (iii) snacks (539 mg/100 g); (iv) seafood and seafood products (383 mg/100 g); and (v) convenience foods (367 mg/100 g).

The WHO has stated that successful policies and interventions for implementation of the SHAKE package include essential elements, such as: (i) political commitment, (ii) programme leadership and governance, (iii) effective partnerships and advocacy, and (iv) integration with iodine deficiency programmes.⁵

Aligned with these strategies, on 11 November 2021, the NaSS team, in collaboration with the NAFDAC, co-organized and co-hosted a multi-stakeholder meeting to facilitate cross-sectoral collaboration, dissemination, and multi-level policy coherence among sectors such as food, health, trade, and law, among others. The hybrid meeting was attended by >400 different stakeholders, including representatives from the Nigeria Federal Ministry of Health, Ministry of Education, WHO, Resolve to Save Lives, academia, food industry, media, and the wider community. Figures 1 and 2 show photographs taken during the meeting.

Figure 1.

Photograph showing a cross-section of stakeholder meeting participants and faculty.

Figure 2.

Photograph showing the two co-principal investigators, the Vice Chancellor, University of Abuja, and the Director General NAFDAC.

One key target of this meeting was to promote dialogue and ensure early buy-in from different stakeholders on how to reduce excess sodium consumption. This meeting serves as an important first step to develop long-term strategies to reduce excess sodium consumption in Nigeria.

Collaborators

National Agency for Food & Drug Administration Control; Federal Ministry of Health of Nigeria; Resolve to Save Lives; Standard Organization of Nigeria; World Health Organization, Nigeria; University of Minnesota; University of Abuja Teaching Hospital; International Society of Media in Public Health; Danisoft Innovative Solutions.

Funding

The Nigeria Sodium Study First Major Stakeholders’ Meeting was funded by National Heart Lung and Blood Institute, USA (grant number: 1UG3HL152381-01); Northwestern University, Chicago, USA; and Resolve to Save Lives.

Conflict of interest: Over the past 3 years, MDH has received extramural research support from the American Heart Association, Verily, and AstraZeneca for work related to food system surveillance in the United States. The other authors have nothing to disclose.