A Portuguese Success Story: One Nation Begins to Curb Its Salt Intake

June 18, 2009

June 18, 2009 (Milan, Italy) — Doctors from the Portuguese Society of Hypertension have spearheaded a unique mass-media campaign about the harmful consequences of consuming too much salt, which in turn has led to the Portuguese Parliament approving a law restricting the sodium content of processed foods [1]. The instigator, Dr Luis Martins (Fernando Pessoa University, Porto, Portugal), recounted his story during a late-breaking trials session here at the European Meeting on Hypertension 2009.

Martins, who says he is now a well-known figure in Portugal due to his appearances on TV, told heartwire that doctors in other countries could follow his lead, but, " colleagues did not achieve this alone--a key factor in the success of the campaign was persuading major celebrities, such as well-known soccer players and children's cartoon characters, to help get their message across.

The widespread media coverage--begun after Martins and colleagues were horrified at the amount of salt they discovered in bread in particular--snowballed into a whole chain of events, including food manufacturers reducing the amount of salt in foods and instituting a "traffic-light" type of warning system on their products, and culminated in the Parliament approving the new law. And of note, at the same time, there was an impressive increase in the awareness of the dangers of consuming too much salt among the Portuguese public, Martins said.

Chair of the late-breaking session, Dr Hans Ibsen (Glostrup University Hospital, Denmark), told heartwire : "What I saw was a very extensive initiative dealing with doctors and politicians and the press working together, and that's a major effort and the way it has to be. You cannot just do it on your own, you need to have all the key players involved, and that's what he [Martins] showed us. And he showed it had an impact and that the producers reduced the salt intake in their bread and food.

"I think it's very important--if you can reduce the salt intake for the whole population and shift their blood-pressure distribution, it has a major impact on the incidence of stroke and also coronary heart disease. The same thing should be tried in all countries."

Portuguese were eating twice the daily recommended amount of salt

If [doctors] want to influence the people, they must act like politicians.

Martins said his crusade began when he noticed how much publicity there was in Portugal about the dangers of high cholesterol levels, but not about consumption of salt. For him, the last straw came three years ago, when an ad on TV claimed that a yogurt kept blood pressure down. He found out from his patients that they had stopped taking their antihypertensive drugs and were eating the yogurt instead. "I called the government, because that was bad publicity, it was disastrous, and I began to think that I must change this."

Given that Portugal has one of the highest mortality rates for stroke in Western Europe--the stroke rate there is twice that of coronary disease--he and his colleagues knew that high salt consumption was likely a major culprit.

So they formed the Portuguese Action Against Salt and Hypertension (PAASH) and began by conducting a pilot study on salt-consumption habits and sources of salt in almost 500 people. They discovered to their dismay that the average Portuguese person was eating 11.9 g of sodium per day, twice the recommended level for adults, and that the amount of salt they consumed correlated with casual and ambulatory blood pressure and aortic stiffness.

They were also surprised to find that Portuguese bread had an average of 19.2 g of sodium per kg, 53% higher than that of bread they surveyed from six other European countries. Given that bread accounts for 21% of daily sodium intake in the country, they realized this was a vitally important source of the excess salt that people were consuming.

Give Us This Day Our Daily Bread, But Reduce the Salt in It

"So we decided this would be our motive to communicate with the public, that bread would be our 'flag' in this fight, and we also enlisted the help of the Portuguese Bakery Association," Martins explained.

In a concerted media campaign in the press, via internet, and on radio and TV, they attempted to raise awareness of the problem. Martins said, for him, an important lesson to learn was, "We must know what the public really knows, not what we think they know. As you know, doctors don't communicate well with the public. We are not dealing with scientists. We must be correct in our communication, but we have to get to people, not to doctors."

He said, in the beginning, he went on every TV show possible to talk about salt and hypertension, but now, "The media have gotten the message, and now they call me to get my advice. They come to me; I don't have to do any more work. But of course it is important to keep this message alive." And central to the campaign's success was the use of celebrities, he stressed: "I could talk to children for hours, but five minutes of a cartoon character telling them the same thing was much more effective."

We must know what the public really knows, not what we think they know.

Alongside the publicity campaign, the PAASH members worked with the Portuguese Bakery Association to develop bread with lower sodium content. "At first, people thought that taking salt out of the bread would affect its quality," Martins said. "But the Bakery Association developed a recipe with less salt but keeping the flavor and the nutrients. We were able to get the salt content of bread down." In addition, other food manufacturers came on board voluntarily, he noted.

Their efforts were rewarded in March this year, when a law was passed by the Portuguese Parliament that makes it mandatory to list the salt content of food and restricts the sodium content in bread and processed foods to a maximum of 14 g/kg.

Almost 75% of Portuguese Public Now Informed About Salt Risks

And a recent survey shows the media message reached its target audience. In 2007, only 29% of the population of Portugal knew the risks of excessive salt consumption, but by 2009 almost three-quarters (72%) considered themselves to be well-informed about the risks of high salt intake. In addition, in 2009, 59% associated salt with hypertension, 44% had changed their salt consumption, and 25% of people had substantially reduced their salt intake during the previous year.

Martins says he particularly wants to influence the children of Portugal, who are suffering from the same problems of overeating and inactivity as children in other nations. "What I want to do really is change the habits of our children, because if the parents are eating an average of 12 g of salt, children are eating far too much salt. So we are creating a future generation of illness. We are taking the message not just to salt, but to healthy food and exercise."

However, he cautioned that successful communication is a careful balancing act: "If we contaminate the essential message too much, it will lose its effectiveness."

Martins and his colleagues estimate that a reduction of just 1 g per day of salt intake would save almost 2500 lives per year in Portugal, which has a population of around 10 million.

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