Regional Framework for Sodium Reduction in Populations

Non-communicable diseases (NCDs) are the main cause of disability and premature deaths in Latin America and the Caribbean. In the Caribbean, cerebrovascular diseases, ischaemic heart disease and diabetes are among the five leading causes of death (Figure 1).

Figure 1. Leading Causes of Death CARPHA Member States, 2000-2016

Source: CARPHA 2019

According to WHO (2012), by 2025, 29 percent of adults in the world will be expected to have elevated blood pressures if appropriate interventions are not implemented. Based on the WHO Steps Survey, more than 80% of CARPHA Member States (CMS) reported the main causes of death during 2000 to 2016 being attributable to cerebrovascular diseases, diabetes mellitus and ischaemic heart disease. In the Caribbean, NCDs contribute significantly to the main causes of deaths over the years 2000-2016 (Figure 2).

Figure 2. Broad Groupings of conditions causing death in the Caribbean.

Source: CARPHA 2019

The greater risk of cardiovascular diseases (CVDs) and stroke has been associated with excessive sodium intake and hypertension. There are several treaties and declarations that inform this Framework (Figure 3).

Figure 3. Treaties and Declarations Related to Chronic Diseases

Initiatives to reduce sodium consumption in the populations of the Region is therefore high on the agenda as a critical aspect of cardiovascular disease prevention and control. Even though the recommended sodium intake is <5g/day (approximately <2,300 mg sodium/day or 1 teaspoon salt/day), its average in most countries ranges from 9g to 12 g per day. The Caribbean is well known for its high dietary consumption of fats, salts and sugars predominantly obtained from processed and ultra-processed foods. Evidence now points to an association between high sodium intake and cardiovascular diseases. While research in the region regarding sodium consumption is limited, anecdotal evidence suggests that the levels of sodium intake in the region exceed recommended levels. To address this problem of excessive sodium consumption, a model framework to guide national strategies for the reduction of sodium intake in the populations was developed.

The Regional Framework

This framework is meant for policymakers, manufacturers, health professionals, and relevant multisectoral stakeholders from public, private and civil society within the region. The scope encompasses action areas to reduce sodium intake at the population level. There are four overarching components of the Framework: Change the Food Environment; Educate the Population; Strengthen Systems Capacity; and Assess Progress (CESA) (Figure 4).

Figure 4. Regional Sodium Reduction Framework: CESA

This framework is adapted from the World Health Organization’s SHAKE technical package (WHO, 2016a).

Vision Goal Purpose Scope of the Framework

This framework envisions a healthy and vital Caribbean people where their average sodium intake falls below the current global target of 5g per day for adults and even less for children. This requires a reduction of approximately thirty percent (30%) in mean population intake of sodium consumption by 2025. This target was informed by the World Health Organization’s Global NCD Target for 2025 which stipulates sodium intake reduction of 30%.

To support CARICOM Member States (CMS) in the reduction of sodium consumption in populations.

This framework is intended for use among CARICOM member states. It outlines strategic actions to reduce national and regional levels of sodium consumption.

This Framework is meant for policymakers, manufacturers, health professionals, and relevant multisectoral stakeholders from public, private and civil society within the region.

How to use this Framework

This Framework is a model that consists of four conceptual building blocks. Based on existing evidence, no single intervention will reduce population sodium intake. It is therefore recommended that users implement a multi-pronged, multi-component approach to achieve the target goal of less than 5 grams sodium intake per day. Each country has its own unique policy landscape at different stages of implementation and intervention, hence the Framework can strengthen system capacity by guiding countries to identify, address and focus on relevant gaps, given the context of existing resources. CARPHA recommends that member states consider the conceptual pillars of this Framework and apply it to their cultural context.

Changing the Food Environment refers to creating supportive food environments. Unhealthy (obesogenic) food environments increase access to and consumption of foods high in sodium, along with foods high in sugar and transfats, contributing significantly to the continued burden of NCDs in the Caribbean region. While there are several ways of changing the food environment, legislation and fiscal mandates have the strongest evidence base of efficacy regarding population behaviour change (WHO, 2016). This Regional Framework focusses on Front of Package Labelling; Nutrition Facts Panels; Nutrition Standards; and Product Reformulation.

Population education helps to instill positive changes to attitudes that could lead to the improvement of the well-being of families and communities. Activities in this area could include campaigns that can take a variety of platforms e.g. public information/education campaigns that focus specifically on sodium or more broadly on diet (including sodium). Regardless of the platform selected, it is crucial to ensure that the intervention effectively increases knowledge and awareness that influence food choices and consumption. In this area, the Regional Framework focusses on educating consumers on general labelling including front of package labelling; adding sodium awareness to the school curricula; and the distribution of sodium spoons throughout the population.

Systems capacity involves existing resources, infrastructure, legislation, standards and protocols to address sodium reduction regionally and locally. The first step to strengthening systems capacity, therefore, entails asset-mapping of existing resources relevant to sodium reduction. These include existing multisectoral and bilateral partnerships, expert committees and activities that act as enablers to further sodium reduction initiatives at all levels. This Regional Framework considers actions such as: collaborating with different sectors to strengthen systems for sodium reduction and resource allocations

Assessing progress requires detailed monitoring of disease incidence in the population, specifically regarding chronic condition with high levels of sodium intake as a known antecedent. Surveillance is therefore critical, and it is imperative to create a comprehensive NCD registry to track incidence and prevalence of all sodium related conditions such as: hypertension, stroke, cardiovascular disease, chronic kidney disease, osteoporosis, and stomach cancer to name a few. This has been considered in the Model Regional Framework for Sodium Reduction.

Sodium Reduction Communications Strategy

This Communications Strategy recommends measures geared at educating people, including children, about the health risks of high sodium intake and how to reduce sodium intake as part of a healthy diet. The Strategy aims to increase knowledge of sources of sodium in the diet; increase knowledge of daily recommended levels; encourage consumers to read food labels; encourage food manufacturers, distributors, vendors and caterers to reduce sodium in prepared foods; and encourage healthy lifestyle practices such as increased consumption of fruit and vegetables. Public education feature highly among strategies to address these issues.

Overall Goal

To support CMS in the reduction of sodium consumption in populations


  1. To sensitise key stakeholders of the Model Sodium CESA Framework
  2. To increase knowledge and change attitudes of populations about the dangers of consuming high levels of sodium (less than 2300 mg sodium ( or one teaspoon of sodium) per day)

To influence food choices of populations and promote the provision, selection and consumption of foods that are lower in sodium

Communication Objectives

To guide CMS in the use of the CESA framework of the framework of sodium reduction and to educate about the dangers of sodium consumption through various audiences

Behavioural Objectives

  1. To support the development and enforcement of front of package labelling on all foods
  2. To read labels on packaged foods and to choose those that are low in sodium
  3. To replace foods with high levels of sodium with healthier food options
  4. To prepare foods low in sodium
  5. To reformulate and produce foods low in sodium
  6. To promote foods low in sodium

Target Audience

  • School children – 5 – 18 years of age
  • Parents and Caregivers
  • Policy makers
  • People with chronic diseases including the elderly and their caregivers
  • Food manufacturers and distributors
  • Political directorate (e.g. Ministers of Government)
  • Primary health care providers
  • Restaurateurs and food vendors
  • Civil society organisations and advocacy groups

General public