1. Barriers related to cultural and social beliefs.

Most participants among the consumers, government representatives and physicians opined that India is a tropical country, where there is excessive sweating and thus a need for a higher salt consumption compared to other countries.

“Myth that like India is a warm country and as we sweat more, we need more salt. These kind of myths are there not only in lay people, but these are there even in the profession.” (Participant from academia)

According to industry representatives and nutritionists, salt reduction requires behavioral change which is quite a complex and time-consuming process. Illiteracy in the population and cultural diversity across different states in terms of the type of foods and preparation methods, vary widely within a state, as well as across states. This was identified as the major barrier for creating behavioral change and increasing awareness among consumers.

“Traditional practices, illiterate people. In India, there is a large section of the population which is not literate, they don’t have an attitude to obey, and they get a great kick to disobey.” (Participant from academia)

“It is important to reduce salt…but kids don’t eat foods with less salt, and even some elderly people throw away food if salt is less.” (Participant consumer)

2. Barriers related to the unorganized food retail sector.

All stakeholders felt that the large unorganized food retail sector, i.e., specifically street vendors who are not under the purview of any food regulations, to be a big challenge. They felt that enhancing consumer awareness to exercise healthier choices could be the solution to this problem.

“Major concern is you have a huge unorganized sector which doesn’t fall under the purview of any regulation.” (Participant from academia)

“It’s difficult… as restaurants have fixed menu. They have their chefs for presenting it. There is a certain pattern. So feel it’s particularly the part of the education, I don’t think more can be done.” (Participant from the government)

“There is no law by which we can interfere with the food content, what is served.” (Participant from civil society)

3. Lack of proper implementation of existing food and dietary policies.

Although there are certain food policies in India, they are not properly implemented. Many participants identified that introducing a new food policy in such a milieu where most existing policies aren’t effectively implemented will be less effective and a time-consuming process.

“In spite of our strict legislation, it won’t work out, in India. The implementation of that law will not happen because of lack of human resources and enforcement.” (Participant from the government)

“Policy or law development will take minimum 5–10 years. So, for immediate action, it should be voluntary. But, we should start meeting people to make law.” (Participant from the government)

4. The decrease in sales.

Most of the stakeholders from the food industry, especially from the unorganized food retail sector had concerns regarding likely decreases in sales as they felt that reduced salt content in the food will affect the consumers’ taste of the food and subsequently have an impact on their sales.

“People will not eat if there are fewer spices and salt in the street food.” (FGD participant)

“Industry has an excuse by saying that people like it only with salt, people have learned to eat with salt as the industry has provided that.” (Participant from civil society)

1. Salt reduction is a major target in the global and national action plan for reducing non-communicable diseases (NCDs).

Salt reduction is a major target under the recently initiated national multi-sectoral action plan for the prevention and control of non-communicable diseases in India.

“The Government is now bound to do that because, under the NCD global targets, salt reduction is one of the key targets and a reporting indicator. In the world assembly, the health minister will have to say how much has been achieved.” (Participant from research bodies)

2. Salt reduction and salt iodization are compatible.

Stakeholders involved with the iodine fortification programme agreed that if salt intake is reduced, the level of iodine in salt can be increased to meet the objectives of the universal salt iodization programme and that both salt reduction and salt iodization can be cost-effective and compatible.

“I think this controversy does not exist in the community as much as it exists among so-called scientists. I think it’s completely false that we have propagated to eat more salt message, the message was always: “eat iodized salt”, that message that will still be there eat iodized salt. So the message of iodine deficiency programme is not going to change.” (Participant from academia)

“Technologically it is feasible to do it, it’s not the major issue, you are adding 15ppm, and you can very well add 7.5 ppm and 10 ppm. Switzerland used to do it, staggered every five years, they used to revise it.”(Participant from academia)

3. Some food industries are already working on salt reduction.

It emerged from the interactions that the food industry, particularly the organized sector is aware of the health impact of excess salt intake and a few of the multinational food companies are already working to reformulate foods to reduce salt content.

“From next year we will label the sodium on the pack, seasoning can be done by microlite salt technology to decrease the sodium, but this can be done on dry products only like chips and namkeen. (a small savory snack or dish).” (Participant from food industry)

“When you look at the food processing industry you have the organized sector, you have Kurkure (this is a brand of corn puffs), you have Lay’s chips, and things like that. Companies like this, I am not sure, but I am hopeful that they would have some strategy to reduce the salt content in their food because they know that high sodium is a public health concern.” (Participant from food industry)

4. Increased awareness about salt reduction among the patient population.

Findings from the consumers FGDs suggest that awareness regarding the excess salt intake and its harmful health effects was largely known to the hypertensive patients and their families. This can also act as a potential facilitator if appropriately leveraged for improving consumer education.

“I know that salt should be reduced in our diet. Doctor informed about the importance of salt reduction in hypertension. Usually I and my family have food with less salt only.” (A hypertensive patient)

“When I was diagnosed with hypertension, doctors informed me to decrease the food with high salt concentration like chips, pickles, and papad (thin, crisp, disc-shaped food from the Indian subcontinent).” (A hypertensive patient)

1. Generate awareness among the consumers, industry and health professionals.

All stakeholders agreed that consumer education is the most important component for a salt reduction effort in India. They indicated that awareness should be generated among all age groups, especially among children and women. In most of the FGDs and consumer interviews, we found that those who have hypertension were aware of salt and its ill effects, but they were unaware about how much salt they should actually consume, how much they are consuming now and how to decrease it. Consumers felt that specific strategies were required to increase awareness, especially on how to reduce the personal salt intake.

“Mass media is an effective way; internet and social networking websites can help in a move towards consuming low salt… then it will become a fashion to ask for a low salt food item. Only then people will.” (Participant from academia)

“You know they really listen to the doctors and implement their advice. Behaviour change comes very fast if doctors tell them… but many times I have observed that… I don’t know… doctors don’t give that much importance to nutrition.” (Participant from food industry)

Most of the physicians and nutritionists suggested that salt reduction awareness should be incorporated into overall dietary guidelines and be integrated into general healthy diet plans and not as a standalone dietary strategy.

“A single component campaign will go into the trash. I think it should be the part of a larger campaign. Because otherwise, people will be sick and tired of… see today its salt, tomorrow its sugar and day after it will be something else, so it should be embedded in a larger campaign of healthy eating. You know it’s simple… salt is bad for blood pressure; something else is bad for something else, so you know people tend to get confused. People should know what a prudent diet is. This is sort of food that is good or bad so they should be taken in certain fashion.” (Participant from academia)

While the food processing industry seems to be aware of high salt consumption and its adverse health consequences, local street vendors are unaware and need to be educated about salt and its ill effects. For increasing awareness among local street vendors and restaurants, professional bodies of Indian restaurant and street food associations can be involved in this initiative.

“Create awareness among manufacturers of the processed food or semi-processed foods or restaurants or hotel or street food vendors.” (Participant from the government)

2. Voluntary and gradual reduction of salt by industry.

Stakeholders from the food industry, government, academia and the civil society agreed that food industry should be made collaborative partners for initiating salt reduction in India. They opined that making a mandatory law for manufacturing low sodium products will take time and will be difficult to implement.

According to physicians and nutritionists, voluntary and gradual reduction of salt in food products will not affect the cost, taste and the sale of the products and may be a feasible way forward.

“Very often salt is added for the taste and attraction of the product, and they would also be reluctant to reduce the salt because it will squeeze out the taste, but a very very gradual and protracted but stage wise reduction would be something that can be done. This will make the industry friendlier to the health of its consumer.” (Participant from academia)

“That is there strong requirement to involve industries; they can actually suggest a lot of things. Because a lot of success of the iodization programme, I will personally like to attribute to the industry as they have picked it up. So, you will definitely have to target the most market share industries and see how it could be. Once the market leaders are convinced to launch a low sodium product, they will attract profit to it.” (Participant from civil society)

3. Improving nutrition labeling and product reformulation.

According to nutritionists, physicians, and academia, the nutrition labeling technique in India is not comprehensive and user-friendly. Given the increased processed food consumption, they felt that having a user-friendly front of pack labeling for all nutritional components will be an effective strategy for enabling healthier food choices. They opined that the policy-makers and the Food Safety and Standards Authority of India (FSSAI) should enforce labeling, and should monitor the enforcement periodically. They were of the opinion that the food industry should bring in newer technologies for reformulation and produce low salt food products.

“If you look at the labeling laws, and labeling on the packs, they are really ancient, first of all consumers don’t look at the label, even if they look at label they don’t understand what to look at and what not to look at, third part is they don’t even know what is good and what is bad. So, labeling should be such that it helps people to make a healthy choice. In some countries have very clear nutrition labeling. You have choices as they have in the Netherlands, which is a tick mark which says it’s a healthy product.” (Participant from the food industry)

4. Incentives for the food industry to produce low salt products.

Many food industry representatives felt that they should be given incentives like tax exemptions on low salt food or provided logos which can be a sign of healthy food. They opined that the Government could make available only low salt food in government hospitals, offices, and other institutions as this will provide a big market to the industry to sustain sales and profits in initial days and then subsequently create awareness among consumers across the society.

“You have to start from somewhere like in all government canteens this can be used, in all government hospitals this low salt food will be used, you have to start from somewhere. You can make it mandatory in places like defense forces to see the immediate benefits. So when critical mass is covered, industries will be functional then they will start educating the people also, and change will come. The Average person will join in the last; he will see that they are not making a fool of me, once he is sure he will join. As the average person is the most vulnerable section of the society.” (Participant from the food industry)

“If you give options to the industry I think that is the best way, also give something to them to latch on to… and if you educate consumer and there is demand from consumers comes up the industry will automatically switch their portfolios, I may start 10% of the product with that particular logo let me say, then the consumer is slowly switching over to that and demanding more, than the ratio may change to 50–60%, you never know how the ratio will change over the time.” (Participant from the food industry)

5. Strengthen research related to salt (sources of salt in Indian diet, actual consumption of salt).

According to the academia, physicians, and government stakeholders, there is need to generate data on country and state-specific actual dietary salt intake and different food sources contributing to the population intake. They indicated that these data would help in the implementation and monitoring of a salt reduction strategy in India.

“First of all we really don’t have very good data on what is the source of salt and all. It is an assumption that it is more due to home-made food, which probably may hold true for the rural area but I am not sure about the urban areas. So first we need to collect these data on what are the sources of salt and then plan accordingly.” (Participant from the government)

Few of the participants indicated that salt substitution could be one possible technique to decrease sodium and increase other components of salt like potassium and magnesium chloride, but they reported the lack of research in this area.

“The best way of reducing salt intake is by increasing saltiness; all the chloride salts have saltiness. Do a food safety analysis of all the chloride salts; you will find some are safe and some are unsafe. Pick up which are good, do the formulation of salt if add 2% of this salt that is Magnesium Chloride (MgCl) to Sodium chloride (NaCl), saltiness of salt will increase what will happen is that if earlier I was taking half spoon now I am taking less salt as saltiness has increased. So this way it can be done.” (Participant from the food industry)

Based on our findings, we have developed a framework highlighting the key strategies and issues to initiate a salt reduction effort in India, which is summarized in Fig 1.

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Fig 1. A Potential framework for initiating salt reduction in India.

https://doi.org/10.1371/journal.pone.0201707.g001