Sodium reduction in New Zealand requires major behaviour change Catherine Lofthouse a , Lisa Te Morenga a , Rachael McLean a, b, * a Department of Human Nutrition, University of Otago, PO Box 56, Dunedin 9054, New Zealand b Department of Preventive & Social Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand article info Article history: Received 18 March 2016 Received in revised form 5 July 2016 Accepted 5 July 2016 Available online 6 July 2016 Keywords: Sodium Consumer behaviour Qualitative New Zealand abstract This pilot study examined the feasibility of adherence to a low sodium diet in a sample of healthy New Zealand adults. It also addressed whether following a low sodium diet was accompanied by changes in intakes of other nutrients that influence cardiovascular risk. Eleven healthy adults provided dietary intake data and a 24-hour urine collection at baseline and follow-up. They then received nutritional counselling based on the World Health Organization recommendation for sodium intake (<2000 mg/ day) and received ongoing nutritional support while undertaking a low sodium diet for four weeks. At the end of the four-week period, participants completed a semi-structured interview that elicited par- ticipants’ opinions on barriers and facilitators to following a low sodium diet and explored changes in participants’ dietary habits and behaviours. Thematic analysis revealed that adherence to a low sodium diet required substantial changes to participants’ usual food purchasing and preparation habits. Partic- ipants reported that lack of control over the sodium content of meals eaten away from the home, the complex and time-consuming nature of interpreting nutrition information labels, and difficulty identi- fying suitable snacks were barriers to adherence. Detailed meal planning and cooking from scratch, using flavour replacements, reading food labels to identify low sodium foods, receiving support from other people and receiving tailored nutrition advice were facilitators. Mean sodium intake reduced over the period, accompanied by a decrease in mean intake of total fat. These factors suggest that sodium reduction in New Zealand adults was feasible. However, considerable changes to eating behaviours were required. © 2016 Elsevier Ltd. All rights reserved. 1. Introduction Improving diet quality is a key component of prevention and treatment of non-communicable diseases (NCDs) (Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases, 2003; World Cancer Research Fund/American Institute for Cancer Research, 2007), which accounted for 68% of global deaths in 2012 (WHO, 2014). In order to reduce the burden of disability, morbidity and mortality due to NCDs, the World Health Organization (WHO) Global Action for the Prevention and Control of NCDs 2013e2020 has outlined nine voluntary global targets for Member States (WHO, 2013). These include the target of a 30% relative reduction in mean population sodium intake by 2025, which could help reduce blood pressure and associated risk of cardiovascular disease (WHO, 2012). Furthermore, WHO recommends that adults consume no more than 2000 mg of so- dium (equivalent to 5 g salt) per day (WHO, 2012). However, actual sodium intakes worldwide far exceed this WHO recommendation. Recent estimates showed that adults worldwide consume an average 4000 mg/day, twice the WHO recommendation (Mozaffarian et al., 2014). In New Zealand, estimated sodium in- takes of adults are approximately 3500 mg/day (McLean, Williams, Mann, & Parnell, 2011; Skeaff, McLean, Mann, & Williams, 2013). Around 90% of dietary sodium is consumed as sodium chloride, or salt. Dietary sodium reduction is difficult because sodium is ubiquitous in the food supply (Cobb, Appel, & Anderson, 2012). In Western-style diets, approximately 75e80% of dietary sodium de- rives from processed food and only 10e15% of intake is added by the consumer while cooking or at the table (Mattes & Donnelly, 1991). In populations following Western-style diets in which there is a high reliance on processed food and eating out, refor- mulation of food to contain less sodium is essential if countries are to achieve a 30% reduction in sodium intake (He, Brinsden, & MacGregor, 2014). The UK salt reduction programme, which * Corresponding author. Department of Preventive & Social Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand. E-mail address: rachael.mclean@otago.ac.nz (R. McLean). Contents lists available at ScienceDirect Appetite journal homepage: www.elsevier.com/locate/appet http://dx.doi.org/10.1016/j.appet.2016.07.006 0195-6663/© 2016 Elsevier Ltd. All rights reserved. Appetite 105 (2016) 721e730