Health Policies on Sodium Levels in Processed Foods

Challenges Encountered

It can be difficult to introduce public health nutrition policies (specifically sodium reduction) at the provincial level, as several changes are introduced to the health protection legislation and public health systems involved (16). Initiating large institutional changes such as nutrition policies, requires consideration of the extensive range of individuals involved, and multiple economic resources required. Also, changes such as sodium reduction, food labelling, or fortification of milk require extensive effort and long periods of time to introduce, establish and maintain. As a result, research is needed to prove that sodium should be reduced in, for example, processed food. Such research involves significant resources (people, money, etc.), and can be very time consuming, often requiring several years.

Nutrition-related changes (such as sodium reduction) proposed by healthcare professionals are difficult for policymakers to implement due to various and clashing factors involved. This requires difficult adaptation by consumers and various modifications by the food industry (10,12). Making such changes is challenging for the food industry, as their food products have a specific nutrient composition (eg. sodium) and modifications to the composition changes the taste and texture of food products. As a result, it is difficult for food industries to determine what addition or removal of ingredient (s) is/are necessary to maintain the satisfaction of consumers. In addition, reducing salt would decrease the product shelf life and affect the safety of the product. Furthermore, consumers are exposed to foods with the same or similar composition over years, when drastic changes are introduced, consumers may not react positively immediately (10,12).  Nutrition policy regarding sodium reduction requires time and should be done in intervals benefiting both the food industry and consumers. As comorbidities of chronic diseases are on the rise, it makes it difficult to determine what requires governance, as multiple cofounding variables are related to chronic diseases, such as sodium, sugar, and trans-fat (16).

My interest in this policy area stems from believing that dietitians can make the largest difference at the population level, and more advocacy should focus on improving the diets of Canadians. I would love to pursue a career in this area of dietetics, and I hope to learn more about the nutrition policies in Ontario, through these assignments.

Institutions, Interests, Ideas

Both levels of government have imperative involvement in food and nutrition policies.  A large focus is placed on the federal government to approve changes to current regulations (eg. trans fat banning) and standards focusing on nutrient content (eg. sodium reduction), food fortification, nutrition labelling and health claims (11, 19). Provincial governments play a proactive and supportive role in dietary guidance implementation. In addition, both levels of government require collaboration with many stakeholders from health professionals, academics, non-governmental organizations and others to promote changes including re-formulating products (eg. lower sodium). *

In terms of sodium reduction in processed foods, the federal government has not approved regulations pertaining to sodium reduction policy (13). However, within the federal level, Health Canada is an important regulatory group advocating for sodium reduction. Health Canada is an intermediate between the government and general public that provides Canadians with resources and tools to improve and well-being.  In addition, Health Canada is accountable, under the Food and Drugs Act (FDA), for the development of standards, regulations and policies associated to foods sold in Canada, to ensure acceptable nutritional quality and food safety standards are followed. Accordingly, one of their key functions is ensuring Canadians are safe by regulating and monitoring food, health and consumer products (4,8,11). *

The legislative framework that closely relates to sodium reduction strategies involves regulation provisions that fall under production, marketing and sale of foods in Canada. The leading act involved in sodium reduction is the Food and Drug Act in the Department of Health, whose key function is ensuring Canadians are protected from health hazards and false claims in the sale of foods. Sections B.01.502 and B.01.513 of the Food and Drug Regulations (FDR) focuses on the acceptable nutrition content claims that can be articulated or inferred (based on composition of nutrients) and their conditions. Furthermore, section B.01.601[1] of the FDA states when disease risk reduction claims are permissible with respect to sodium, when food products have low composition, which is the goal of sodium reduction strategies (4, 10). *

Requests made by Health Canada are addressed and approved by Minister of Health and Long-Term Care based on certain criteria. Approval is dependent upon adequate evidence that the change will be greatly favorable to the health of Canadians. Furthermore, the office of Health Promotion federal efforts endorse sustenance of good health based on the recommendations of Health Eating Strategy (6,14). As a result, they play an important role in dietary guidance, promotion & knowledge translation, surveillance, research & data analysis and policy leadership & collaboration (2, 11).  *

The College of Dietitians of Ontario is a regulatory body within the federal government that helps to ensure the dietetic regulatory framework reflects the current dietetic practice. Dietitians of Canada (DC) is an important group in this policy area working with various regulatory bodies and advocacy groups, a member of the Sodium Working Group, and monitors activities in Health Canada’s Eating Strategy. Furthermore, DC promotes the need for a national database where monitoring and surveillance can improve the understanding of gaps in the food supply and evaluate the nutritional intake of Canadians (7).

In addition to governing bodies, many in-field organizations and advocacy groups, who overlap, play a role in this policy area. For example, some groups include Nutrition Facts Education Campaign, Eat-Well and Food-Epi Research Committee. Blood Pressure Canada (now Hypertension Canada) and the Heart and Stroke Foundation are two leaders among non-governmental groups that inform Canadians about the implications of high sodium intake (3, 19, 21).

Existing Provincial Regulations

Currently, there are no existing provincial regulations for sodium reduction in Ontario.

Based on the evaluation results of the Sodium Working Group, provinces were promoting greater investments in sodium reduction research by all involved parties (18). Provinces and members of the Sodium Working Group have advocated for sodium reduction through research committees, monitoring/evaluation of current programs, and through public awareness and education. However, in the report received in January 2017 (stating progress made), the food industry was not successful in their approach of sodium reduction (13,18). Both federal and provincial Ministers of Health have emphasized sodium reduction as a nutrition priority and recommended a target RDA of 2300mg/d by 2016. This has yet to be approved with the expected year now moved to 2020. Due to this unsuccessful approach to sodium reduction, monitoring and surveillance undertakings are imperative in determining the best practices for sodium reduction (13,18).

Existing Programs

There are many existing programs that affect nutrition policies in Ontario; two key ones are provided by Dietitians of Canada (DC) and Hypertension Canada. The programs provided by these two institutions are vital in sodium reduction as they both provide educational programs and resources for all Canadians. DC provides both preventative and treatment-focused education programs that tackle sodium reduction strategies for all age groups. It provides online resources including “sodium sense” fact sheets for all ages, offering guidance in order to make informed and healthier selections. DC is essential in contributing to improved nutritional intake and well-being through their continuous advocacy and efforts towards sodium reduction (7). In addition, locally, Toronto Public Health provides programs that educate Toronto residents towards reducing salt in their diets (20).

Hypertension Canada provides educational programs online and within communities to establish effective strategies to address high sodium intake. This program provides guidance for both healthcare professionals and the general public concerning (but not limited to) sodium reduction. Some tools provided by Hypertension Canada include: what meals should consist of, resources available to monitor daily intake how to read nutrition labels to avoid high sodium, and what to include/exclude in your meals (1, 21).  *

Policy Changes

There are no policies set in place for sodium reduction in Ontario. In the past, major steps have been taken towards the development of one, but none have been successful. Ontario’s Bill C-460 on sodium reduction was one bill under consideration, but rejected by the Federal Government in 2013.  This health public policy set voluntary targets to reduce sodium levels for food manufactures. If reducing the composition of sodium was not possible, the food manufactures needed to clearly state and warn consumers that the food product was high in sodium. This bill was intended to allow Canadians to make health-conscious choices as information of sodium levels on food products was straightforward.

Many benefits could have resulted from implementation of this policy. With Bill C-460, reduction and regulation of sodium composition in food products would have undoubtedly helped to combat elevated cases of chronic diseases/conditions such as high blood pressure and stroke. According to research, Bill C-460, long term wise would have reduced DAYLS, reduced premature death and enhanced the efficiency of Canada’s economy, saving billions in healthcare costs (5, 10, 14).

However, one challenge encountered was sodium reduction in processed foods by food companies is still in progress (even in 2018), as majority of the food industry has reduced sodium levels to required values stated by Health Canada. Very minimal or no changes have been made by food manufactures in a goal that was supposed to be achieved at the end of 2016. One main challenge is the reformulations in the composition of salt, which usually plays a technical or safety role in food, has indefinitely made it difficult for manufacture. For example, salt is essential in its influence on the texture and flavour of aged cheese, or simple flavour profiles like tomato juice that only contain three ingredients (salt being one of them) would be difficult to alter and recreate (10, 12,13). In addition, consumers’ acceptance is another key problem, as can be noted by Campbell’s reduction of sodium in their soups, which resulted in significant sale slumps (15). Subsequently, Campbell’s company discarded their sodium reduction efforts, providing limited options with low sodium soups, and returning sodium composition to their previous formulations (15). Furthermore, food industries need to consider cost and resources to make drastic changes to processed foods (12, 13, 14).

Health Canada has introduced to the public mandatory front-of-package labelling of nutrition symbols for foods high in sodium, sugar and saturated fat. Health Canada has stated a label will be required in food products that have more than 15 per cent of the daily recommended intake. This mandatory front of package labelling for foods high in sodium will be beneficial as it provides easy access to useful information. The clear symbols and visuals will provide easy guidance when making informed food products purchased. In addition, this may encourage food industries to improve nutritional quality and value of packaged foods, to ensure adequate sales.

However, as this development is still in the very early stages, progress into a policy requires an extensive period of time for the food industry making these changes on all their products. Moreover, this policy implementation appears to over-value certain nutrients, and these symbols may not be enough to discourage consumers from purchasing processed foods high in sodium and fat (9). *

Conclusion

Nutrition policies surrounding sodium reduction in Ontario are a small subset of the broad policy area of public health nutrition. Controlled at both the federal and provincial level, there are multiple governing bodies that promote, establish and monitor nutrition policies. This policy area falls under the legislative framework of many acts, including the Food and Drug Act. However, there are no provincial regulations relating specifically to sodium reduction of processed foods. There are many challenges that need to be combatted to effectively work towards mandatory (not voluntary) targets for sodium reduction in processed foods. Effective sodium reduction policies are important in working towards improving the health, well-being of the community and reducing the healthcare system budget.

Articulation of Policy Area

High rates of disability and morbidity in Canada are due to the development of chronic diseases partially as a result of poor nutrition. A key contributor to these chronic health conditions is high sodium consumption. Since most Canadians now consume 1100mg/d more than the required daily intake (2300mg/day), managing comorbidities has become increasingly difficult in the last century. It is estimated diagnoses of high blood pressure is present among roughly 25% of Canadians, over the age of 20 (17, 18). High sodium consumption among Canadians contributes to one third of these cases (14). Overall, high sodium consumption can result in stomach cancer, impaired kidney function, and osteoporosis (17, 19). Pre-packaged processed foods contribute to high levels of sodium (in addition to fat and sugar) intake among Canadians (1,14, 18). This paper will be primarily focusing on the policies surrounding sodium levels in processed foods.

It is important to note social, personal, economic factors and sustained quality of life requires good health and well-being. A healthy and productive society decreases the burden on the health care system and improves the economy. In addition, a safe and nutritious food supply is vital to overall health and well-being of individuals.

Enabling food/nutrition sector changes requires the involvement of eager administrators and policy-makers. Decision-makers support an inter-sectoral approach when superior sectors (federal government) emphasize the importance of nutrition policies regarding public health.

Policy development and implementation requires input from various sectors including health, education, environmental, agriculture and the food industry. (6, 19). Nutrition policies are essential in combating current health issues and improving health promotion (for prevention) by government parties and all sectors. Through an efficient method of communication, and set policies, there should be reduction in incidence of excessive sodium intake of Canadians.

Within public health nutrition, sodium reduction policies are highly crucial due to the rising rates of comorbidities. The safety of Canada’s food supply is highly dependent on the roles of the government, food supply and consumers. Public Health professionals are pivotal players in monitoring nutrition-related issues and advising improvements in the approaches of nutrition and health education delivery in sodium reduction. Overall, the collaboration with stakeholders who are eager keen on tackling today’s issue of high sodium consumption and support from government in developing policies are critical (1,6,11,12).

Challenges Encountered

It can be difficult to introduce public health nutrition policies (specifically sodium reduction) at the provincial level, as several changes are introduced to the health protection legislation and public health systems involved (16). Initiating large institutional changes such as nutrition policies, requires consideration of the extensive range of individuals involved, and multiple economic resources required. Also, changes such as sodium reduction, food labelling, or fortification of milk require extensive effort and long periods of time to introduce, establish and maintain. As a result, research is needed to prove that sodium should be reduced in, for example, processed food. Such research involves significant resources (people, money, etc.), and can be very time consuming, often requiring several years.

Nutrition-related changes (such as sodium reduction) proposed by healthcare professionals are difficult for policymakers to implement due to various and clashing factors involved. This requires difficult adaptation by consumers and various modifications by the food industry (10,12).Making such changes is challenging for the food industry, as their food products have a specific nutrient composition (eg. sodium) and modifications to the composition changes the taste and texture of food products. As a result, it is difficult for food industries to determine what addition or removal of ingredient (s) is/are necessary to maintain the satisfaction of consumers. In addition, reducing salt would decrease the product shelf life and affect the safety of the product.Furthermore, consumers are exposed to foods with the same or similar composition over years, when drastic changes are introduced, consumers may not react positively immediately (10,12).  Nutrition policy regarding sodium reduction requires time and should be done in intervals benefiting both the food industry and consumers. As comorbidities of chronic diseases are on the rise, it makes it difficult to determine what requires governance, as multiple cofounding variables are related to chronic diseases, such as sodium, sugar, and trans-fat (16).

My interest in this policy area stems from believing that dietitians can make the largest difference at the population level, and more advocacy should focus on improving the diets of Canadians. I would love to pursue a career in this area of dietetics, and I hope to learn more about the nutrition policies in Ontario, through these assignments.

Institutions & Interests

Both levels of government have imperative involvement in food and nutrition policies.  A large focus is placed on the federal government to approve changes to current regulations (eg. trans fat banning) and standards focusing on nutrient content (eg. sodium reduction), food fortification, nutrition labelling and health claims (11, 19). Provincial governments play a proactive and supportive role in dietary guidance implementation. In addition, both levels of government require collaboration with many stakeholders from health professionals, academics, non-governmental organizations and others to promote changes including re-formulating products (eg. lower sodium). *

In terms of sodium reduction in processed foods, the federal government has not approved regulations pertaining to sodium reduction policy (13). However, within the federal level, Health Canada is an important regulatory group advocating for sodium reduction. Health Canada is an intermediate between the government and general public that provides Canadians with resources and tools to improve and well-being.  In addition, Health Canada is accountable, under the Food and Drugs Act (FDA), for the development of standards, regulations and policies associated to foods sold in Canada, to ensure acceptable nutritional quality and food safety standards are followed. Accordingly, one of their key functions is ensuring Canadians are safe by regulating and monitoring food, health and consumer products (4,8,11). *

The legislative framework that closely relates to sodium reduction strategies involves regulation provisions that fall under production, marketing and sale of foods in Canada. The leading act involved in sodium reduction is the Food and Drug Act in the Department of Health, whose key function is ensuring Canadians are protected from health hazards and false claims in the sale of foods. Sections B.01.502 and B.01.513 of the Food and Drug Regulations (FDR) focuses on the acceptable nutrition content claims that can be articulated or inferred (based on composition of nutrients) and their conditions. Furthermore, section B.01.601[1] of the FDA states when disease risk reduction claims are permissible with respect to sodium, when food products have low composition, which is the goal of sodium reduction strategies (4, 10). *

Requests made by Health Canada are addressed and approved by Minister of Health and Long-Term Care based on certain criteria. Approval is dependent upon adequate evidence that the change will be greatly favorable to the health of Canadians. Furthermore, the office of Health Promotion federal efforts endorse sustenance of good health based on the recommendations of Health Eating Strategy (6,14). As a result, they play an important role in dietary guidance, promotion & knowledge translation, surveillance, research & data analysis and policy leadership & collaboration (2, 11).  *

The College of Dietitians of Ontario is a regulatory body within the federal government that helps to ensure the dietetic regulatory framework reflects the current dietetic practice. Dietitians of Canada (DC) is an important group in this policy area working with various regulatory bodies and advocacy groups, a member of the Sodium Working Group, and monitors activities in Health Canada’s Eating Strategy. Furthermore, DC promotes the need for a national database where monitoring and surveillance can improve the understanding of gaps in the food supply and evaluate the nutritional intake of Canadians (7).

In addition to governing bodies, many in-field organizations and advocacy groups, who overlap, play a role in this policy area. For example, some groups include Nutrition Facts Education Campaign, Eat-Well and Food-Epi Research Committee. Blood Pressure Canada (now Hypertension Canada) and the Heart and Stroke Foundation are two leaders among non-governmental groups that inform Canadians about the implications of high sodium intake (3, 19, 21).

Existing Provincial Regulations

Currently, there are no existing provincial regulations for sodium reduction in Ontario.

Based on the evaluation results of the Sodium Working Group, provinces were promoting greater investments in sodium reduction research by all involved parties (18). Provinces and members of the Sodium Working Group have advocated for sodium reduction through research committees, monitoring/evaluation of current programs, and through public awareness and education. However, in the report received in January 2017 (stating progress made), the food industry was not successful in their approach of sodium reduction (13,18). Both federal and provincial Ministers of Health have emphasized sodium reduction as a nutrition priority and recommended a target RDA of 2300mg/d by 2016. This has yet to be approved with the expected year now moved to 2020. Due to this unsuccessful approach to sodium reduction, monitoring and surveillance undertakings are imperative in determining the best practices for sodium reduction (13,18).

Existing Programs

There are many existing programs that affect nutrition policies in Ontario; two key ones are provided by Dietitians of Canada (DC) and Hypertension Canada. The programs provided by these two institutions are vital in sodium reduction as they both provide educational programs and resources for all Canadians. DC provides both preventative and treatment-focused education programs that tackle sodium reduction strategies for all age groups. It provides online resources including “sodium sense” fact sheets for all ages, offering guidance in order to make informed and healthier selections. DC is essential in contributing to improved nutritional intake and well-being through their continuous advocacy and efforts towards sodium reduction (7). In addition, locally, Toronto Public Health provides programs that educate Toronto residents towards reducing salt in their diets (20).

Hypertension Canada provides educational programs online and within communities to establish effective strategies to address high sodium intake. This program provides guidance for both healthcare professionals and the general public concerning (but not limited to) sodium reduction. Some tools provided by Hypertension Canada include: what meals should consist of, resources available to monitor daily intake how to read nutrition labels to avoid high sodium, and what to include/exclude in your meals (1, 21).  *

Policy Changes

There are no policies set in place for sodium reduction in Ontario. In the past, major steps have been taken towards the development of one, but none have been successful. Ontario’s Bill C-460 on sodium reduction was one bill under consideration, but rejected by the Federal Government in 2013.  This health public policy set voluntary targets to reduce sodium levels for food manufactures. If reducing the composition of sodium was not possible, the food manufactures needed to clearly state and warn consumers that the food product was high in sodium. This bill was intended to allow Canadians to make health-conscious choices as information of sodium levels on food products was straightforward.

Many benefits could have resulted from implementation of this policy. With Bill C-460, reduction and regulation of sodium composition in food products would have undoubtedly helped to combat elevated cases of chronic diseases/conditions such as high blood pressure and stroke. According to research, Bill C-460, long term wise would have reduced DAYLS, reduced premature death and enhanced the efficiency of Canada’s economy, saving billions in healthcare costs (5, 10, 14).

However, one challenge encountered was sodium reduction in processed foods by food companies is still in progress (even in 2018), as majority of the food industry has reduced sodium levels to required values stated by Health Canada. Very minimal or no changes have been made by food manufactures in a goal that was supposed to be achieved at the end of 2016. One main challenge is the reformulations in the composition of salt, which usually plays a technical or safety role in food, has indefinitely made it difficult for manufacture. For example, salt is essential in its influence on the texture and flavour of aged cheese, or simple flavour profiles like tomato juice that only contain three ingredients (salt being one of them) would be difficult to alter and recreate (10, 12,13). In addition, consumers’ acceptance is another key problem, as can be noted by Campbell’s reduction of sodium in their soups, which resulted in significant sale slumps (15). Subsequently, Campbell’s company discarded their sodium reduction efforts, providing limited options with low sodium soups, and returning sodium composition to their previous formulations (15). Furthermore, food industries need to consider cost and resources to make drastic changes to processed foods (12, 13, 14).

Health Canada has introduced to the public mandatory front-of-package labelling of nutrition symbols for foods high in sodium, sugar and saturated fat. Health Canada has stated a label will be required in food products that have more than 15 per cent of the daily recommended intake. This mandatory front of package labelling for foods high in sodium will be beneficial as it provides easy access to useful information. The clear symbols and visuals will provide easy guidance when making informed food products purchased. In addition, this may encourage food industries to improve nutritional quality and value of packaged foods, to ensure adequate sales.

However, as this development is still in the very early stages, progress into a policy requires an extensive period of time for the food industry making these changes on all their products. Moreover, this policy implementation appears to over-value certain nutrients, and these symbols may not be enough to discourage consumers from purchasing processed foods high in sodium and fat (9). *

Conclusion

Nutrition policies surrounding sodium reduction in Ontario are a small subset of the broad policy area of public health nutrition. Controlled at both the federal and provincial level, there are multiple governing bodies that promote, establish and monitor nutrition policies. This policy area falls under the legislative framework of many acts, including the Food and Drug Act. However, there are no provincial regulations relating specifically to sodium reduction of processed foods. There are many challenges that need to be combatted to effectively work towards mandatory (not voluntary) targets for sodium reduction in processed foods. Effective sodium reduction policies are important in working towards improving the health, well-being of the community and reducing the healthcare system budget.

Hence, it is important to consistently keep up with food and nutrition policies from international, national, and local levels as new scientific evidence is discovered (16).

References

1. Arcand, J., Au, J. T., Schermel, A., & L’Abbe, M. R. (2014). A comprehensive analysis of sodium levels in the Canadian packaged food supply. American journal of preventive medicine, 46(6), 633-642.

2. Bill C-460. An Act respecting the implementation of the Sodium Reduction Strategy for Canada.(2012). 1^st reading, November 5, 2012, 41^st Parliment, First Session. Ottawa:House of Commons of Canada. Retrieved Oct 3, 2018 from http://www.parl.ca/DocumentViewer/en/41-1/bill/C-460/first-reading/page-14

3. Campbell, N. R., Willis, K. J., L’Abbe, M., Strang, R., & Young, E. (2011). Canadian  initiatives  to prevent hypertension by reducing dietary sodium. Nutrients, 3(8), 756-764.

4. Canadian Food Inspection Agency. Helath Claims (2018). Government of Canada. Retrieved from http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/health-claims/eng/1392834838383/1392834887794?chap=0

5. Canadian Nurses Association (2018). Sodium Reduction Strategy. Retrieved from:https://www.cna-aiic.ca/en/policy-advocacy/chronic-disease-prevention-and-management/sodium-reduction-strategy

6. Department of Finance Canada. (2016). Federal support to provinces and territories. Retrieved: from http://www.fin.gc.ca/access/fedprov-eng.asp#Major Note in particular pages on Canada health transfer (2012) and History of the health and social transfers (2014).

7. Dietitians of Canada (2018). Sodium Reduction. Dietitians of Canada. Retrieved from:  https://www.dietitians.ca/Dietitians-Views/Food-Regulation-and-Labelling/Sodium-Reduction.aspx

8. Health Canada. (2011). Canada’s health care system. Government of Canada. Retrieved from  https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html

9. Health Canada (2018). Consultation on proposed front-of-package labelling. Retrieved from: https://www.canada.ca/en/health-canada/programs/consultation-front-of-package-nutrition-labelling-cgi.html

10. Health Canada (2012). Guidance for the food industry on reducing sodium in processed foods. Bureau of Nutritional Sciences, Food Directorate, Health Products and Food Branch.  Retrieved from: https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/pdf/legislation/guide-ld/2012-sodium-reduction-indust-eng.pdf

11. Health Canada (2012). Office of Nutrition Policy and Promotion. Retrieved from: https://www.canada.ca/en/health-canada/corporate/about-health-canada/branches-agencies/health-products-food-branch/office-nutrition-policy-promotion.html

12. Health Canada (2017). Sodium Reduction in Processed Foods in Canada: An Evaluation of Progress toward voluntary targets 2012 to 2016. Retrieved from: https://www.canada.ca/en/health-canada/services/food-nutrition/legislation-guidelines/guidance-documents/guidance-food-industry-reducing-sodium-processed-foods-progress-report-2017.html

13. Health Canada (2016). Symposium on Sodium Reduction in Foods Meeting Report. Retrieved from  https://www.canada.ca/en/services/health/symposium-sodium-reduction-foods-meeting-report.html

14. Joffres, M. R., Campbell, N. R., Manns, B., & Tu, K. (2007). Estimate of the benefits of population-based reduction in dietary sodium additives on hypertension and its related  health care costs in Canada. The Canadian Journal of Cardiology, 23(6), 437–443.

15. Lott, Joshua (2018). Campbell’s adding salt back to its soups. The Globe and Mail. Retrieved from  https://www.theglobeandmail.com/life/health-and-fitness/campbells-adding-salt-back-to-its-soups/article587037/

16. Mozaffarian, D., Angell, S. Y., Lang, T., & Rivera, J. A. (2018). Role of government policy in nutrition—barriers to and opportunities for healthier eating. BMJ, 361, k2426.PHAC (2013).

17. Public Health Agency of Ontario (2018). How Healthy are Canadians? A tend analysis of the health of Canadians from a healthy living and chronic perspective. Health Canada. Retriveed from https://www.canada.ca/en/health-canada/services/publications/food-nutrition/sodium-intake-canadians-2017.html

18. Public Health Ontario (2012). Repository Ontario Sodium Summit Proceedings.  Ontario Sodium Summit.  Retrived from: https://www.publichealthontario.ca/en/eRepository/Ontario_Sodium_Summit_Proceeding_2012.pdf

19. Sodium Working Group. (2010). Sodium reduction strategy for Canada. Ottawa:Health Canada.

20. Toronto Public Health (2010). Sodium Reduction Strategy. Retrieved from: https://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33043.pdf

21. Van Vliet, B. N., Campbell, N. R., & Canadian Hypertension Education Program. (2011). Efforts to reduce sodium intake in Canada: why, what, and when?. Canadian Journal of Cardiology, 27(4), 437-445.