1. Evaluating Sodium Initiatives Rashon I. Lane, M.A. Evaluation and Program Effectiveness Team Division for Heart Disease and Stroke Prevention September 14, 2010

2. Disclaimer Statement The information presented here is for training purposes and reflects the views of the presenter. It does not necessarily represent the official position of the Centers for Disease Control and Prevention.

3. Overview of Today’s Session Today’s session will address the following: Examples from other public health initiatives Evaluation questions and indicators Example model for evaluating sodium initiatives

4. Why Sodium Reduction? Excess sodium intake is a known risk factor for high blood pressure and CVD events. Average consumption of sodium in the United States is far greater than recommended limits. – 2005 Dietary Guidelines recommendation: <2,300 mg/day (1,500 mg for specific populations) – Average intake: 3,466 mg/day The majority of sodium consumed comes from processed and restaurant foods. Policy and environmental changes are needed to speed decreases in sodium intake.

5. Relative Amounts of Dietary Sodium in the American Diet Source: Mattes RD, Donnelly, D. Relative contributions of dietary-sodium sources. J Am Coll Nutr. 1991 Aug;10(4):383-93.

6. Similar Foods Have Less Sodium in the U.K. U.S. sodium/serving 210 mg U.K. sodium/serving 160 mg U.S. sodium/serving 220 mg U.K. sodium/serving 120 mg

7. Sample Food Label, U.S.

8. Sodium Reduction Policies and Strategies ProcurementLabeling Venue Based StrategiesMedia to support policy/environmental change

9. Procurement Policies designed to make the healthy food more available, affordable, and appealing. They can work to change individual factors (i.e., knowledge of how to choose healthy options), social factors (i.e., social norms), and environmental factors (i.e., access to healthy options).

10. Labeling Studies Studies assess: – Awareness – Knowledge – Consumer choices/behavior Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City – http://content.healthaffairs.org/cgi/content/full/28/6/w1110 http://content.healthaffairs.org/cgi/content/full/28/6/w1110 Stanford Study Shows Posting Calories on Restaurant Menu Boards Lowers Customers’ Calorie Counts per Visit – http://www.gsb.stanford.edu/news/starbucks.html http://www.gsb.stanford.edu/news/starbucks.html

11. Venue Based Strategies Worksites Schools Hospitals

12. Example Media Evaluation Champlain (Canada) “GIVE YOUR HEAD A SHAKE” Sodium Reduction Media Campaign Evaluation Design -Telephone survey repeated 6, 12, & 24 months post launch of campaign. -Respondents (n=1,600 per community) of Champlain and control community -Assess attitudes, knowledge and behaviors of related to dietary sodium 2010. Champlain Cardiovascular Prevention Network Annual Report 2009-10

13. Example Media Evaluation Results Four-in-ten respondents say the campaign has been instrumental in getting them to reduce their sodium intake – Most respondents are concerned about eating too much sodium – 70% are trying to cut back on the amount of sodium they are eating – 50% of respondents were not able to correctly identify many high sodium foods – Many respondents report regularly eating foods high in sodium 2010. Champlain Cardiovascular Prevention Network Annual Report 209-10

14. Why Evaluate Now? Determine if policies or environmental changes are effective in attaining expected outcomes [e.g., knowledge, attitude, consumer behavior] Share lessons learned among public health practitioners and other partners.

15. Logic Models Mediating Factors Individual Factors -Increased knowledge of health effects of sodium -Increased knowledge of how to choose low sodium foods Increased intention to consume low sodium foods Decreased sodium consumption Decrease blood pressure Label sodium content of foods Health Impact Biological -Increased sensitive ‘taste of salt” -Decreased sodium preference Potential Food Procurement Policy Components Promote healthy low sodium options Decrease cost of healthy low sodium options Increase the availability of low sodium options Social Factors -increase positive social norms around reducing sodium consumptions Environmental Factors -increase access to low sodium options Decrease affordability gap of low sodium options

16. Example Procurement Evaluation Questions Process – To what extent have agencies implemented procurement standards? Have agencies met standards? Were manufactures able to meet standards? What were the resources needed? Outcome – What is the impact of the policy... on cost of certain foods? on the food or nutrients (such as sodium) that clients consume? on client health (i.e. blood pressure, weight)?

17. Indicators and Data Sources Proportion of procurement policy/standards for foods purchased, served or sold that are passed Proportion of agencies adhering to policy/standards Proportion of meals served that have lower sodium options Data Sources – Documentation of policies passed – Purchase records – Point of purchase/sales data – Audits of agency menus – Dietary surveys (consumer level)

18. Group Activity 1.Choose a strategy or intervention 2.Select 2 possible evaluation questions (process and outcome) 3.Determine what indicators will help answer these questions. 4.Determine if there is an existing data source or if one can be developed.

19. Evaluation Plan Template ActivityEvaluation QuestionData SourceData Collection/Analysis Implement procurement standards for food nutrients to include sodium To what extent have agencies complied with new standards? Purchase records/receipts/ menus Pre/post-purchase records/receipts/menus audit.

20. Related Workshops Reducing Sodium Intake—What Are the Policy Opportunities? (WK-12) The BRFSS 2012 Salt Intake Module ─ Possible State-Added Questions in 2011 (19-A)

21. Q & A

22. Contact Information Rashon Lane E-mail: rlane@cdc.gov