High consumption of sodium, one of the components in table salt, is a wellestablished risk
factor for high blood pressure and cardiovascular diseases. Reducing intakes to recommended
levels would benefit public health and therefore efforts to achieve this are being made by
national authorities, nongovernmental organisations and food industry.
The World Health Organization (WHO) recommends that adults consume no more than 5 g salt per
person per day, yet actual consumption in Europe today is substantially higher at 812 g.
1
The health
benefits that could be achieved by lowering the salt consumption have given rise to salt reduction
initiatives in many countries of the European Union (EU), and in 2008 the EU Framework for National Salt
Reduction initiatives was adopted.
2
The idea of the EU framework is to support ongoing national initiatives through coordinating
actions and disseminating useful information while striving towards a common goal.
3
Since major sources of salt in our diet are processed and restaurant foods, the food industry plays a key role in salt intake
reduction. This has been recognised by organisations leading national salt reduction programmes, and collaboration with the
food industry is often a key component in those programmes. In addition, many food producers and retailers, on their own
initiative, address high salt consumption by product reformulation, but also through awarenessraising campaigns and labelling
initiatives.
1
Lowering salt content in foods
Salt is added to foods for its taste, but also to enhance other flavours, to preserve foods by inhibiting food spoilage micro
organisms and to achieve certain textures. Thus, reformulation is not a task of simply lowering the salt content to the desired
level. The technological challenge is to reduce salt levels while maintaining taste and other product quality attributes, including
safety.
One approach is to gradually lower the amounts of salt in a food product. We get used to a certain level of saltiness and tend to
find the food bland if salt content is reduced drastically in one step. However, if the salt content of a product is reduced in small
steps we do not necessarily notice any difference, and we gradually get used to a less salty taste. Reductions of 2025% are
usually possible without serious taste problems. Stepwise salt reduction is most effective if all manufacturers within one food
category agree on a strategy and carry it out simultaneously.
1,2
To a certain extent, regular table salt (sodium chloride) may also be replaced by other mineral salts which do not contain sodium,
e.g. potassium chloride. However, the saltiness of other mineral salts is not as intense as that of regular salt and in addition they
may give a bitter or metallic flavour. One way to get around this problem is to use additional compounds that mask the
bitterness. Alternatively, the flavour enhancing effects of salt may be compensated for by adding more herbs, aromas and spices
to the product.
Along with stepwise salt reduction and replacement, new methods to reduce salt in foods are being developed. For example,
ingredients that may enhance the sensitivity of the salt receptors on the tongue, which would increase the perceived saltiness of a
food, are being researched. Another approach that is explored by food manufacturers is salt distribution in foods, i.e. reducing
salt levels in certain fractions or components of a food may allow an overall lowering of the salt content without negative impact
on the taste.
1
Information and labelling
Besides food reformulation, salt reduction programmes in many cases aim at raising public awareness of the potential
detrimental effects to health of high sodium intakes as well as providing tips on how to lower sodium intakes. Labelling systems
often are in place to inform consumers on sodium or salt levels in products. Although in the EU nutrition labelling is voluntary
(unless nutrition or health claims are made), certain national regulatory exceptions exist. For example, in Finland labelling is
mandatory for important sources of salt such as meat products, bread and ready meals. If such foods exceed certain levels of
salt this has to be indicated on the packaging.
4
Salt reduction programmes are they effective?
The majority of national initiatives to reduce salt intakes are relatively recent and therefore their impact on salt consumption
often remains unclear. However, in Finland, where a salt reduction programme has been in place since 1975, the average salt
intake among adult Finns has declined from then 12 g per day to 9.3 g per day in men and 6.8 g per day in women.
5
Another
example is the UK where a salt reduction programme was introduced in 2003.
6
At that time the average salt intake levels were
9.5 g per day, whereas in 2008 it was 8.6 g per day.
These results indicate that reductions in salt consumption take time, but it has been estimated that even modest reductions could
lead to substantially less cardiovascular events and thus improve public health.
7
For more information
Food Today n°66. The role of sodium in sports drinks.
www.eufic.org/article/en/page/FTARCHIVE/artid/Sodium
Addressing salt intakes in Europe
Food
Today
n°56.
Salt,
potassium
and
the
control
of
blood
www.eufic.org/article/en/page/FTARCHIVE/artid/saltpotassiumbloodcontrol/
Food Today n°25. A Grain of Salt and a Grain of Sense?
www.eufic.org/article/en/page/FTARCHIVE/artid/saltand
References
1. Busch J et al. (2010). Salt reduction and the consumer perspective. New Food 2/10:3639.
2. European Commission (2009). Reformulating food products for health: context and key issues for moving forward in
Europe. Working paper on reformulation for health the way forward. Available at:
http://ec.europa.eu/health/nutrition_physical_activity/docs/ev20090714_wp_en.pdf
3. European Commission (2009). National Salt Initiatives. Implementing the EU Framework for salt reduction initiatives.
Available at:
http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/national_salt_en.pdf
4. Ministry of Trade and Industry Decree 1224/2007 on amendments to Sections 24 and 25 of the MTID on food packaging
markings, adopted in Helsinki on the 13 of December 2007.
5. Paturi M, Tapanainen H, Reinivuo H, Pietinen P, eds. Finravinto 2007 tutkimus – The National FINDIET 2007 Survey.
Publications of the National Public Health Institute, B23/2008, 228 pages.
6. Food Standards Agency (2008). An assessment of dietary sodium levels among adults (aged 1964) in the UK general
population in 2008, based on analysis of dietary sodium in 24 hour urine samples.
http://www.food.gov.uk/multimedia/pdfs/08sodiumreport.pdf
7. BibbinsDomingo K et al. (2010). Projected effect of dietary salt reductions on future cardiovascular disease. New
England Journal of Medicine 362(7):590599.
2
Consumers are constantly faced with new information regarding the health and safety of their
food. However, recent evidence suggests consumers remain concerned over their food supply.
Understanding current barriers to communicating the risks and benefits of food and identifying
potential remedies for such challenges are the objectives of the European Commissionfunded
project FoodRisC. This project seeks to produce a practical toolkit that enables effective and
balanced food risk communication.
Introducing FoodRisC
Balanced food risk communication remains a challenge across the European Union (EU), with ongoing public concern about
food supply contaminants, technological advancements, and dietrelated diseases (e.g., diabetes and obesity).
1,2
Multiple
information sources with different perspectives further consumer confusion and the potential for misinformation or
misinterpretation.
3
Enormous progress has been made in understanding the determinants of consumer risk perception and in
identifying effective food risk communication strategies, but such progress has not been matched by appropriate strategies and
tools to deliver the information.
The European Commissionfunded project Food Risk Communication – Perceptions and communication of food risks/benefits
across Europe (FoodRisC) seeks to address such communication challenges by characterising key food risk and benefit
relationships, exploring the potential of new social media, and providing a systematic understanding of how consumers deal with
food risk and benefit information. The FoodRisC consortium is comprised of experts in key fields relevant to food risk and benefit
communication from research institutes, consumer organisations, and SMEs in ten EU Member States. The consortium is
supported by an Advisory Board of representatives from eight renowned organisations in health communication (including the
European Food Safety Authority, the World Health Organization, and Google) and coordinated by Professor Patrick Wall of
University College Dublin’s School of Public Health and Population Science. The FoodRisC project’s ultimate goal is to produce a
toolkit and practical guidance that target and tailor coherent food risk and benefit messages to consumers across Europe.
FoodRisC Objectives & Methods
The FoodRisC project has four major objectives:
1. Describe key configurations of food risk and benefit relationships and the implications for communicators.
2. Explore the potential of new social media (e.g., blogs and social networks, such as Facebook and Twitter) and provide
guidance on how risk communicators can best use these media for food risk and benefit communication.
3. Characterise the ways in which consumers attain, interpret, and utilise information to help target populations and tailor
messages.
4. Propose a strategy and communication toolkit for the effective communication of coherent messages across EU Member
States.
These objectives will be met through a range of research approaches and methods that extend the traditional framework of food
risk and benefit communication. Traditionally, the food communication framework relays information from an authoritative source
through a classical media channel (e.g., television, internet, print) to consumers. The FoodRisC project adapts the traditional
communication model to include the active role of recipients of the information, and incorporates the way in which various
demographic variables (e.g., gender, socioeconomic status, age) serve as barriers to consumer understanding. FoodRisC will also
build on the findings of other EU projects including Beneris (BenefitRisk Assessment for Food: an Iterative ValueofInformation
Approach), Qalibra (Quality of life integrated benefit and risk analysis), PASSCLAIM (Process for the Assessment of Scientific
Support for Claims on Foods) and BRAFO (RiskBenefit Analysis of Foods).
What’s New? Novelty of FoodRisC
Over the last 15 years, there has been extensive research into risk perception and communication across a range of scientific
disciplines with recent research highlighting the importance of considering consumer perception of risks and benefits.
4
However, little research has been done to develop and implement communication tools that overcome the demographic
challenges in consumer understanding of food risks and benefits.
Accordingly, the FoodRisC project is novel in seeking to not only identify the barriers to effective, balanced food risk and benefit
communication, but to discover new approaches to overcoming such barriers including the potential of social media, the use of
tailored messaging, and the standardisation of key food risk and benefit configurations. In addition, the project is not limited to
‘food scares’, which often garner media attention, but moreover FoodRisC focuses on everyday examples of foodrelated
communications that more directly impact the lives of consumers.
What’s the goal? Impact of FoodRisC
FoodRisC seeks a European level impact with the development of the FoodRisC toolkit together with practical guidance to
enable the effective communication of coherent messages across EU Member States. The toolkit will integrate information
gathered on barriers to consumer understanding with novel approaches to overcoming such barriers.
EUFIC serves as both a research and dissemination partner seeking to research and provide a systematic understanding of how
consumers deal with food risk/benefit information. The FoodRisC toolkit in conjunction with effective dissemination and training
will directly improve the current practice of food communication among national and international policy groups while ultimately
advancing EU health initiatives.
Further information
FoodRisC
podcast with coordinator Professor Patrick Wall
Evaluating perceptions and communication of food risks & benefits across
Europe
3
FoodRisC receives research funding from the European Commission’s 7th Framework Programme, contract n° 245124.
EUFIC Review An Introduction To Food Risk Communication. Available at:
www.eufic.org/article/en/foodsafety
quality/riskcommunication/expid/reviewfoodriskcommunication/
References
1. Foster R and Lunn J. (2007). "40th Anniversary Briefing Paper: Food availability and our changing diet." Nutrition Bulletin
32(3):187249.
2. Smillie L and Blissett A. (2010). A model for developing risk communication strategy. Journal of Risk Research 13
(1):115134.
3. Miller GD et al. (2006). American Journal of Clinical Nutrition, Vol. 83, No. 6, 12721275
4. Frewer LJ, Scholderer J, Bredahl L. (2003). Communicating about the risks and benefits of genetically modified foods:
The mediating role of trust. Risk Analysis 23:1117
4
Ensuring food safety is a shared responsibility between governments, producers, industry and
consumers. Food labelling is one way in which consumers can get knowledge about the food they
consider buying. Correctly following the information provided on food labels (such as expiry dates,
handling instructions and allergy warnings) can help consumers prevent unnecessary foodborne
illness and allergic reactions.
Expiry dates
In the European Union (EU), an intricate set of legislation and standards has been developed and implemented to ensure safety
throughout the entire food chain. Perishable foods, judged from a microbiological point of view (such as cooked meat products,
prepared foods and salads), display a 'use by' date on the package and should not be eaten after this date, as this could
present a health risk. In addition, many foods display a ‘best before’ date, which gives an indication of the “minimum
durability”, or the period during which the food retains its specific properties when properly stored. In other words, a product
whose “best before” date has expired may still be safe to eat, but the manufacturer no longer guarantees the sensory
properties of the product (e.g. taste, smell, appearance etc).
In a recent nationally representative survey from the UK, only half (49%) of the over 3000 respondents correctly identified the
‘use by’ date as the best measure of safety and 47% said they would never eat cooked meat beyond its 'use by' date.
1
Most
respondents were found to be using expiry dates as a point of reference and relying on their own judgement to decide if the food
was safe to eat by smelling it (74%) or by just looking at the food (65%). In a nationally representative study from Ireland (796
respondents), only 39% of people regularly referred to the food label of a product, and of these, only half referred to the best
before/use by dates on a food label.
2
Other studies in the EU have reported similar findings.
35
It should be borne in mind though
that food can be contaminated with food poisoning bacteria such as Listeria and Salmonella without an odour or a change in
product appearance.
Storage, preparation and cooking information
Storage instructions are required on certain food products in combination with the expiry date to ensure proper handling by
consumers. Food poisoning bacteria such as Salmonella and Listeria can grow to levels that may cause illness if food is not
stored correctly. These instructions may also indicate how to store the food once the package is opened (e.g., ‘Refrigerate
after opening’). Although consumers often use storage conditions and preparation guidelines, it is usually only when they buy a
new product and not when it is a product they have previously purchased. In a recent quantitative study, 1012 Irish consumers
were asked to rate the importance of mandatory labelling information for prepackaged foodstuffs.
6
The majority (over 70%)
regarded storage conditions and ‘instructions for use (where necessary)’ as important information on the label. In another
study from Ireland, only 12% of the 796 respondents said they referred to the cooking instructions when looking at food labels
and even less, 9%, regularly refer to storage instructions.
2
These studies indicate that while consumers say that information on
storage, preparation and cooking information of food on labels is important, they may not use this information very often.
Allergy warnings
Other important information on food labels includes allergy warnings which help consumers who have specific food allergies, to
avoid those allergens that may be present in specific food products. EU legislation requires labelling of 14 substances that are
known allergens in some people.
7
The requirement is to label them only when they are present. In other words, there is no
labelling of absence, unless a product would be targeted at a population that has a specific allergy or food intolerance (e.g.
gluten free).
Consumers with food allergies have reported spending a lot more time on grocery shopping to find suitable products but
sometimes have noticed a lack of information about the inclusion of potential allergens in the food products they would like to
eat.
8,9
A study to understand the attitudes of British parents of children with nut allergy towards labels informing that the
product could contain nuts revealed that 80% of parents would not purchase a product labelled 'not suitable for nut allergy
sufferers' or 'may contain nuts'.
10
However, other labels including 'this product does not contain any nuts but is made in a
factory that uses nuts', 'cannot guarantee is nut free' and 'may contain traces of nuts' were avoided by only around 50% of
parents. These results indicate that food product labelling remains confusing to those with food allergies leading to risktaking
by either ignoring warning labels on foods or assuming that the wording reflects the gradation of risk.
References
1. Food Standards Agency (FSA) (2009). Public attitudes to food. Available at:
http://www.food.gov.uk/multimedia/pdfs/publicattitudestofood.pdf
, accessed on 30 May 2010.
2. safefood (2009). Safetrak 9 Island of Ireland. A presentation of findings. Available at:
http://www.safefood.eu/PageFiles/1412/Web%20edition%20Safefood%20Safetrak%209%20IOI%
, accessed on 30 May 2010.
3. Verbeke W and Ward RW. (2006). Consumer interest in information cues denoting quality, traceability and origin: An
application of ordered probit models to beef labels. Food Quality and Preference 17:453467.
4. Terpstra MJ et al. (2005). Food storage and disposal: consumer practices and knowledge. British Food Journal 107
(7):526533.
5. Eurobarometer (2005). The European consumers’ attitudes regarding product labelling. Available at:
http://ec.europa.eu/consumers/topics/labelling_report_en.pdf
, accessed on 30 May 2010.
6. FSAI (2009). A Research Study into Consumers Attitudes to Food Labelling. Available at:
http://www.fsai.ie/assets/0/86/204/9f8b5edc565e4f108c0f7015f742da09.pdf
, accessed on 30 May
2010.
7. Commission Directive 2007/68/EC of 27th November 2007:
lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2007:310:0011:0014:EN:PDF
8. CornelisseVermaat JR et al. (2005). Europrevall report on consumer preferences regarding food allergen information.
EU project Europrevall. Available at:
http://www.efanet.org/activities/documents/REPORTEuroprevallreport4.pdf
.
Food labelling A wealth of information for consumers
5
9. Mills ENC et al. (2004). Information provision for allergic consumers – where are we going with food allergen labelling?
Allergy 59:12621268.
10.
Noimark L et al. (2009). Parents' attitudes when purchasing products for children with nut allergy: a UK perspective.
Paediatric Allergy Immunology 20:500504.
6
Many chronic health problems are associated with modifiable lifestyle behaviours, such as
poor dietary choices and physical inactivity. Existing behaviour patterns are, however,
notoriously difficult to change, even when the individual recognises that their health is at
risk. Health care professionals have a vital role in motivating their patients to adopt
healthier lifestyles but effective strategies for change involve more than simply offering
advice.
Motivational counselling
Traditionally, health care providers have adopted a ‘directive’ style of counselling their patients on healthrelated behaviours,
giving information and instructions on changes that are deemed necessary.
1
Whilst this paternalistic approach may be
appropriate for some individuals, it can inadvertently increase resistance in other patients.
2
A sustained change in behaviour is achieved more effectively when the motivation to do so is elicited internally by the patient
rather than imposed by others.
1
Behaviours are thus reinforced by internal rewards related to the individual’s needs, interests and
emotions. Patientcentred techniques, such as motivational interviewing and collaborative goal setting, aim to promote internal
motivation and have been associated with improved health outcomes.
35
Such techniques encourage patient autonomy in deciding
what changes are necessary and how they can be achieved.
Ready….
Behaviour change is a gradual process, accomplished in stages through which the patient must progress.
6
Not all atrisk
individuals will be ‘ready’ to change and behavioural interventions should be tailored accordingly. Raising awareness of the
problem and providing relevant information in a nonconfrontational manner may help increase an individual’s readiness to
change.
5
….willing….
Healthrelated behaviours are determined by a person’s understanding of the issues involved and by their perception of how
relevant these issues are to their personal circumstances. For change to occur, they must believe that their behaviour makes
them vulnerable to a particular health problem, that the problem is potentially serious, and that the benefits of taking action
outweigh the potential costs.
7
Social factors, such as social norms or ideals and the attitudes of friends and family, can also
influence a person’s willingness to engage in behavioural change.
….and able
Fear of failure can be an important barrier to change. Health care professionals have an important role in enhancing the
patient’s selfefficacy, or confidence in their own ability to realise a particular goal. This involves not only providing
reassurance and constructive feedback, but also giving them the skills and resources they need to achieve success.
‘Goal setting and action planning’ is one tool that can help patients to improve diet and physical activity, particularly when they are
planned in collaboration with a health professional.
4,8
Action plans with a high probability of success are preferable, since even
small successes can increase patient self esteem and motivation. The SMART acronym has been used as a guideline for setting
suitable goals and refers to goals that are Specific, Measurable, Achievable, Relevant and Timeframed.
9
Practical guidelines
l
Identify a target behaviour that would benefit the patient’s health.
l
Discuss the link between behaviour and health, and the patient’s perception of its relevance to their own situation.
l
Assess the patient’s readiness to change, according to the degree of resistance encountered, and tailor the consultation
accordingly.
l
Avoid being judgmental or confrontational and do not persist in advocating change when resistance is high.
l
Explore and empathise with the patient’s own motivations, feelings and beliefs. Encourage them to weigh up the pros
and cons of behaviour change in their own words.
l
If a decision to change appears imminent, guide the patient towards formulating their own action plan.
l
Encourage them to set SMART goals (up to three), incorporating behaviours that can be easily integrated into their
current lifestyle and have a high probability of success. Support from family, friends or other patients may help achieve
those goals.
l
Discuss potential barriers to change and how the patient plans to deal with them.
l
Provide access to information and other resources that will support the patient in the process. Individualised computer
generated materials can be beneficial.
l
Maintain contact, provide feedback and encourage selfmonitoring of progress.
l
Recognise that relapse is common and does not constitute a failure of the process. Discuss options with the patient to
deal with unmet goals.
Probably every therapist can benefit from the general nonjudgmental, nonpaternalistic tone of these motivational techniques. It
should be recognised though that using them competently takes time and determination, and interested therapists are advised to
seek professional guidance and training.
References
1. Rollnick S et al. (2005). Consultations about changing behaviour. BMJ 331:961963.
2. Miller WR. (2005). Enhancing patient motivation for health behavior change. Journal of Cardiopulmonary Rehabilitation
Motivating change: Tips for health care professionals
7
25:207209.
3. Rubak S et al. (2005). Motivational interviewing: a systematic review and metaanalysis. British Journal of General
Practice 55: 305312.
4. Handley M et al. (2006). Using Action Plans to Help Primary Care Patients Adopt Healthy Behaviors: A Descriptive
Study. Journal of the American Board of Family Medicine 19:224231.
5. Britt E et al. (2004). Motivational interviewing in health settings: a review. Patient Education and Counseling 53:147155.
6. Prochaska JO et al. (1992). In search of how people change: Applications to addictive behaviours. American Psychology
47: 11021114.
7. Elder JP et al. (1999). Theories and Intervention Approaches to HealthBehavior Change in Primary Care. American
Journal of Preventive Medicine 17:275284.
8. MacGregor K et al. (2006). BehaviorChange Action Plans in Primary Care: A Feasibility Study of Clinicians. Journal of
the American Board of Family Medicine 19:215223.
9. Siegert RJ and Taylor WJ. (2004). Theoretical aspects of goalsetting and motivation in rehabilitation. Disability and
Rehabilitation 26:18.
8