Background

Cardiovascular diseases (CVDs), mainly coronary artery disease and stroke, are the leading cause of death worldwide, accounting for 31% of total global deaths [1]. Malaysia is not exempted from this; in fact, the Department of Statistics Malaysia reported an increase in deaths due to cardiovascular disease (ischemic heart disease) from 15% in 2019 to 17% in 2020 [2]. Of all the risk factors, hypertension was reported as the main contributor to the CVDs, which affects 30% (approximately 6.4 million) of Malaysians aged 18 years and older [3]. The WHO estimated that 1.7 million annual deaths from CVDs were attributed to excess dietary sodium intake [4] and the Malaysian Community Salt Survey conducted in 2017–2018 showed that 79% of Malaysians take an excessive amount of salt [5]. On average, Malaysians consume about 7.9 g salt (or 3167 mg sodium) per day. which is above the WHO recommended salt intake of 5.0 g per day [5, 6].

Salt reduction is among the most cost-effective measures in the prevention of cardiovascular diseases [7]. The WHO has set a global target of 30% reduction of salt intake by 2025. This has encouraged many countries in the world to speed up their salt reduction efforts. The strategies include food reformulation, consumer education, front pack labelling and interventions in public institution settings. Bread was the most targeted food for reformulation, followed by bakery products, processed meats, dairy products, sauces and convenience meals [8]. More countries are now opting for structural or regulatory approaches, however, efforts must be urgently accelerated and replicated in many countries and more rigorous monitoring and evaluation of strategies is needed to achieve the salt reduction target [9]. Within the South East Asia regions, only a few countries have dedicated stand-alone salt reduction policies; most are embedded in their national health/nutritional policy or overall noncommunicable disease (NCD) policies [10].

Malaysia began its salt reduction initiative in 2010 when a salt reduction committee was formed under the noncommunicable disease (NCD) section, Disease Control Division, Ministry of Health (MOH). The MOH announced a reduction of salt in 11 food items including soy sauce. Furthermore, the salt reduction committee collaborated with several agencies to increase awareness of salt and promote salt reduction in Malaysia [5]. The salt reduction strategy for Malaysia in 2015–2020 aimed at achieving the voluntary global target reduction of 30% in the mean population intake of salt/sodium by the year 2025. The midterm evaluation of this Salt Reduction Strategy 2015–2020 by WHO showed that there was only moderate progress in terms of delivering outputs to the Malaysian population and poor progress in engaging food manufacturers to reformulate food with less salt. Additionally, progress was also slow on salt reduction messages and education materials, particularly on the need to lower processed food intake. Thus, a continuation of the national reduction strategy has been outlined for 2021–2025, with a long-term target of 6.0 g of salt intake per day by the year 2025. Six recommendations to strengthen the salt reduction strategy were proposed, one of which was to address salt levels in the out-of-home sector [11]. The out-of-home sectors could be divided into a formal sector that includes registered and licensed restaurants, cafes, fast food outlets and takeaways, while the informal sector includes street food vendors or hawkers and informal food deliveries [12].

According to Department of Statistics Malaysia, about 17.3% of household expenditure was on foods and nonalcoholic beverages, while about 13.9% was on restaurants and hotels [13]. This data indirectly show that the out-of-home sectors are among the sources of foods that have an impact on sodium intake in the population. Out-of-home food intake is popular as it provides immediate or ready to eat foods. Thus, there is a need to specifically outline strategies to reduce salt consumption in out-of-home food sectors. To develop these strategies, further understanding of the out-of-home food industries and manufacturers as well as that of policy makers are needed.

This study aimed to determine the perceptions, barriers and enablers of salt reduction in the out-of-home sectors among the policy-makers, nongovernmental organizations (NGOs) and researchers, as well as the food industry. This study is part of a larger study on “Developing a policy to reduce the salt content of food consumed outside the home in Malaysia,” involving all formal and informal sectors [14, 15].

Methods

Study design and ethics

This study was a qualitative study in which participants were asked to openly share their views on the study matter, including the perceptions, barriers and enablers of salt reduction in Malaysia, with emphasis on the out-of-home sectors through 19 sessions of semi-structured in-depth interviews (IDI) and three sessions of focus group discussions (FGD). Due to the COVID-19 pandemic throughout the study period (May 2020 to March 2022) [16], a mixed approach of online meetings via the Google Meet application and face to face were carried out throughout the study. This research involved targeted stakeholders that were identified as related to the salt reduction policy, i.e., policy-makers and food industries. Ethics approvals were obtained from Universiti Kebangsaan Malaysia Medical Research Ethics Committee (UKM PPI/111/8/JEP-2020–524), the Malaysian National Medical Research Ethics Committee [ NMRR-20-1387-55481 (IIR)] and Queen Mary (University of London) Research Ethics Committee (QMERC2020/37) prior to the data collection. Written informed consent was obtained from all participants. To ensure confidentiality, pseudonyms were used in all interviews and transcriptions of the data has been anonymized. Identifiable information of participants was only used for arranging the interviews and obtaining signed consent, while demographic data was compiled in a table. Records were stored securely on a password protected computer, while the consent form was stored separately in a locked cabinet.

Study framework and questionnaire

Questionnaires used in this study was developed based on a combination of framework modified from the Medical Research Council (MRC), UK [17], Ecological Model [18] and Theoretical Domains Framework (TDF) [19], as described elsewhere [14]. The basic framework adopted the development and feasibility domain from the MRC, while the Ecological Model and TDF were used to specifically refine the development process consisting of specific domains to answer the research question. Two set of questionnaires were developed, pretested and piloted in this study (Appendix A). The first questionnaire targeted the policy-maker, while another set is tailored towards the food industry. The questionnaires were pretested and piloted separately in a group of policy maker (i.e., two representative of policy-makers) and food industry (i.e., three representatives of food industry). After the pretesting and pilot study, the questionnaires were paraphrased to make it clearer to both the interviewer and respondents in the subsequent data collection. Since the amendment only involved paraphrasing of a few sentences, not involving major change of the domain of the questionnaire, the respondents involved in the pilot study were included as the actual sample for data collection.

Sampling procedure and data collection

Sampling

The samples of this study were policy-makers and the food industries. A policy-maker is defined as those who creates ideas and plans, especially those carried out by a government. The policy-maker involved in this study included representatives from the ministry/government agencies acting as the primary policy-maker. Other stakeholders usually involved in policy-making including researchers from nutrition, food science/food technology from universities, or government agencies and NGOs who indirectly play the role in supporting the salt reduction policy were also included. The list of policy-makers and food industries was obtained from various sources including the Technical Working Group for Salt Reduction Policy of the Ministry of Health (MoH), the Food Industry Association of Malaysia (FAM), government agencies such the Federal Agricultural Marketing Authority (FAMA), the Malaysian Fisheries Development Authority (LKIM) and the Malaysian Agriculture Research and Development Institute (MARDI).

In this study, the ministry/government agencies involved were representatives from four divisions of the Ministry of Health (MoH) namely Noncommunicable Disease Division, Food Division, Food Safety and Quality Division, Nutrition Division and representatives from the Ministry of Education (MoE), Ministry of Domestic Trade and Consumers Affairs and the Ministry of Agriculture (MoA) and its agencies, which were the Federal Agricultural Marketing Authority (FAMA), Malaysian Fisheries Development Authority (LKIM) and Malaysian Agriculture Research and Development Institute (MARDI). Inclusion criteria of representatives of each organization included an officer or person in charge or well versed with food or salt reduction strategy or policy for at least 6 months. Five nongovernmental organizations (NGOs)/professional societies that participated in this study included the Malaysian Dietitians’ Association, the Malaysian Association for the Study of Obesity, the Family Medicine Specialists’ Association of Malaysia, the Malaysian Society Nephrology and the Malaysian Society of Hypertension. The researchers involved in this study were from several universities in Peninsular Malaysia and MARDI. The representatives from ministries, government agencies and NGOs were mostly based in the west of Peninsular Malaysia and four government agencies were from the Borneo region. There were representatives of policy-makers from the government agency from each of the regions, in line with the samples of the food industries. The distribution of the participants according to stakeholders and regions are presented in Table 1. Invitation letters were sent through e-mail to all the participants and appointments with them were made before the interview and discussion sessions. Invitations were sent to 13 policy-makers, 6 NGOs and 25 food industries. The response rate was 77% for policy-makers (n = 10), 83% for NGOs (n = 5) and more than 100% food industries (n = 65). Total response rate was 91%. For policy-makers, there were some ministries/government agencies that were invited who sent more than one participant in the IDI session, hence for ten ministries/government agencies, there were a total of 15 participants attending the sessions. For NGOs, only one participant for each NGO attended the IDI session. For the food industries, a snowball technique was applied and huge participation was recorded as some of the industries attended were not in the list of the invitation but their participation was significant to reach saturation for the data on the food industry.

Table 1 Distribution of participants according to stakeholders and regions
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In-depth interviews (IDI) were conducted mostly online with policy-makers (ministry, government agency and researcher) using a specific questionnaire. The in-depth interview (IDI) was conducted by an interviewer (researcher) that been trained to conduct the IDI session using standard protocol and questionnaire. At each session, a moderator or interviewer will conduct the interview, with assistance from a co-moderator and a rapporteur. Prior to the IDI, the interviewer started with a short introduction and briefing. The interviewer asked the respondent to open their camera and ensured that their microphone was in a good condition. The interviewer let the respondent answer the questions based on his/her own views and thoughts. The interview lasted for approximately 1 hour, then the interviewer would wrap up the session with key points highlighted by the respondents or participants. Focus group discussions (FGD) were conducted face to face following a standard operating procedure (SOP), as outlined by the Ministry of Health (MOH) involving groups of researchers and the food industries.

Data analysis

All participants were assigned a code number and pseudonym. The code and pseudonym were used to identify quotes and comments made by the interviewees. The quotes and comments made by the interviewees were coded according to gender, stakeholder, region group. The policy-maker stakeholder was further divided according to the designated group (ministry/government agency or researcher or NGO) and numbered accordingly. The food industries were coded according to gender, food industries’ category and region, and numbered accordingly. The interviews and the discussions were recorded using a voice recorder. The recordings were verbatim transcribed after the session was completed. The transcripts were analysed thematically using Nvivo software (version 12; QSR International, Doncaster, Victoria, Australia). Electronic data including recordings of interviews and discussions as well as transcripts were stored in shared drives with specific password access within Universiti Kebangsaan Malaysia (UKM), and were only accessible to trained research team members.

Results

As presented in Table 2, the mean age was 40 years old (range 21–74 years), with the majority being women (66%) and having received tertiary education (53%). Specifically, among the food industries, most had secondary education (57%). A quarter of the participants of the food industry were from snack food (25%) and processed food industries (22%).

Table 2 Sociodemographic data of the participants [presented as mean, n (%)]
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In this study, we identified several themes related to salt reduction in the out-of-home sectors in Malaysia, categorized under “Perception on salt intake and salt reduction policy in Malaysia,” “Barriers in salt reduction policy,” and “Motivation/enablers on salt reduction.”

Perception on salt intake and salt reduction policy in Malaysia

Generally, all participants in this study agreed that the salt intake among Malaysians is high and leads to health problems. They have highlighted several factors that influenced Malaysians to take high salt foods/food products such as the use of various sauces, salted fish, anchovies and food seasoning in food preparation. In addition, they have also shared their thoughts on the salt reduction policy including positive perception on the policy to reduce salt intake and ineffectiveness/insufficiency of the current policy, as well as opinions on the implementation of the policy. Table 3 summarizes the perception of the salt intake and salt reduction policy in Malaysia.

Table 3 Perception of salt intake and salt reduction policy in Malaysia
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The current salt reduction policy by the Ministry of Health (MOH) includes guidelines to reduce salt in food products, sodium labelling, reformulation of foods, training and awareness campaigns as well as recognition and incentives that attract the food industries to reduce the salt content in their food products. Table 4 lists some of the salt reduction policies by the MOH and the practices of the food industries with regards to the policy.

Table 4 Salt reduction policy and industrial practice
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Barriers and enablers of the salt reduction policy

There were several barriers, motivations enablers to salt reduction that have been proposed by the policy-makers and food industry participants. The barriers and motivation/enablers’ themes were divided into several categories including awareness, behaviour, consumer acceptance, knowledge, reformulation, resources, guidelines and salt target, priority, support, monitoring and law enforcement, price and cooking (Table 5).

Table 5 Barrier and motivation/enablers of the salt reduction policy
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Discussion

Our study showed that most of the participants agreed that the salt intake among Malaysians is high, as many food products including fast foods, snacks, processed foods, fermented foods and traditional foods, as well as food in the out-of-home sectors are high in salt content. The top ten food items that contributed to the highest sodium consumption among adult Malaysians include kolok mee, light soy sauce, curry noodle, vegetable with soy sauce/oyster sauce, fried instant noodle, noodle soup, vegetable with salted fish, fried vegetable, roti canai/roti telur and fried rice [20]. Findings by the Singapore National Nutrition Survey 2018 showed that the use of seasoning, sauces and salt in food preparation make up three-quarters of salt consumed in the diet [21]. Several of these foods are mentioned in this study by the participants and could be easily purchased as out-of-home foods.

Most of the participants in this study were aware of the association between high salt intake and health problems such as hypertension and cardiovascular diseases, and showed a positive perception towards the salt reduction policy to reduce the burden of these diseases. Continuous education and increased awareness among the population on salt reduction through electronic and mass media have been suggested by most of the participants. They also highlighted that very few campaigns/education pertaining to salt reduction could be found on television and social media as compared with other food components such as sugar. Other countries, such as the UK, reported similar findings [22]. Creating awareness among the consumers, food industries and health providers has been suggested as the first step in the salt reduction initiative as it will increase understanding on choosing foods with less salt, provide knowledge on the recommended daily salt intake and methods on preparing food with less salt [23]. However, since 2014, there has been a fall in consumer education around the world. This could be partially due to the fact that this strategy is resource and time-intensive, thus making it difficult to maintain [9]. The Ministry of Health of Malaysia [24] has also shared a similar view. There are calls for others such as nongovernmental organizations (NGO) to assist salt reduction advocacy, similar to what has been done by the Malaysian Society for World Action on Salt, Sugar and Health (MyWASSH), as endorsed by the World Hypertension League and the International Society of Hypertension [25]. Other NGOs that participated in this study did not indicate a specific plan in line with salt reduction strategies and policies.

Food labelling is one of the most important communication tools that can give information about the nutrient content of a food product, and hence can increase the awareness and knowledge on the salt content of an actual food product. However, not all food industry participants were aware of the announcement by the Ministry of Health for mandatory sodium labelling by July 2020, to be enforced by the year 2024 (26). The Healthier Choice logo has been introduced in Malaysia as a voluntary labelling, and encourages the food industries to produce healthy products since April 2017 [27]. However, its effectiveness on reducing the salt intake of the population has not been determined. There is a need to further explore perception of food industries on food labelling, as a recent study among Czech producers indicated that although there is a positive effect of food labelling on marketing, however, the effect on economic gain is not much [28].

Funding specifically for research and reformulation of lower salt foods was also emphasized as needed by most of the participants to produce lower salt foods. Several foods such as bread, meat, dairy and convenience foods have been successfully reformulated and contributed to the reduction of salt intake among the population in the UK [29]. Malaysia has reformulated about 53 food product categories including instant noodles, flavored cakes, sauces, biscuits, snacks and frozen meats, with a reduction of about 2–80% of their salt content. However, only a few of these reformulated products are high contributors of salt in diets, which makes a limited impact on overall intake of salt in the population [24].

Evidence from the UK and other countries has shown that reducing salt is relatively easy for manufacturers as it does not affect the products’ weight or volume and there are few technical barriers. Only for a small number of products does salt have a technical function. However, the large variations in the salt content of similar products clearly show how much salt can still be innocuously removed. Furthermore, consumers do not perceive any change in taste as salt is reduced gradually.

Salt is a poor preservative and is now rarely used as a preservative as other chemicals are more effective. There are also other technologies such as high-pressure, ultrasound, microwave and vacuum curing which have been adopted in the production of low-sodium fermented products and for the reduction of microbial contamination, acceleration of the fermentation process, improvement of texture and color, reduction of amount of salt added and shortening of the salting periods [30,31,32,33,34]. Improving the physical form of sodium salt to increase its dissolution and diffusion rate is one of the physical strategies that is also used in fermented foods [35].

The use of a salt substitute such as potassium chloride (KCl), calcium chloride (CaCl2), magnesium chloride (MgCl2), potassium lactate, calcium lactate and calcium ascorbate shows no risk of spoilage and pathogenic bacteria. However, these salt alternatives may produce a bitter taste, thus they could not completely replace the NaCl [36]. On the other hand, the use of salt synergists such ethanol and spices also have been utilized to increase the flavor and physicochemical properties of low salt products [37]. The use of functional microorganisms, microbial metabolites and enzymes could also improve the products’ quality and safety [38, 39]. Nevertheless, most of the respondents from the industries in the present study were not aware of techniques to reduce salt in their products without jeopardizing the shelf life and consumer acceptance.

Monosodium glutamate (MSG), which is widely used in cooking as food enhancer, has been suggested to increase the sodium content; however, several studies have reported that the addition of MSG in reduced salt foods could lower the sodium content in the foods. MSG contains two-thirds less sodium than NaCl and the saltiness is reportedly associated with a G-protein coupled receptor that enhances the perception of saltines [40, 41]. The permittable amount of MSG as a food additive in the range of 0.1–0.8% is equivalent to the amount of free l-glutamate found naturally in tomatoes and parmesan cheese [42]. Hence, we propose that the use of MSG needs to properly follow the recommendations for avoiding excessive use that leads to increased sodium content in foods. Our recent market survey indicated that processed foods with MSG added were among the foods with high sodium content [43].

The food industries also found difficulties in reducing the salt as they needed to follow the unrevised Food Act, which requires a fairly high amount of salt to achieve safety of food products. Hence, the current Food Act needs to be revised for a new salt target so the food industries can make the reformulations. Salt targets have been shown to effectively reduce salt intake in UK salt reduction strategy [44]. Many countries have shifted to approaches of salt reduction that change the food environment, such as providing lower salt options to the population and opting for regulation to support the change, such as through mandatory targets for salt levels in foods, mandatory front-of-pack labelling, mandatory nutrition standards in settings and salt taxation [9]. There were suggestions by policy-makers in this study on salt tax and subsidies for low salt foods. Salt tax has been implemented in various countries such as Fiji, Hungary, Mexico, Saint Vincent and the Grenadines, and Tonga on high salt foods and prepacked foods that exceed the recommended salt limit. In 2019, Thailand proposed a salt tax on high salt food including frozen products, canned foods and instant noodles [9]. Imposition of tax on high salt foods and subsidies for low salt foods could potentially result in a consumer choice for lower salt foods because of cost savings compared with their usual normal consumption [45]. In the current scenario of global increases in food price and inflammation, this strategy should be evaluated further.

The study has successfully obtained the perception, barriers and enablers towards a salt reduction strategy among policy-makers and the food industry. This qualitative study suggests the following: (i) Enhancing communication between policy-makers and the food industries to ensure shared responsibility in salt reduction strategies, (ii) introducing a visible front-of-pack label on food high in salt content, (iii) setting targets for voluntary salt reduction of a selective category of food high in salts, (iv) low-cost advocacy and education towards a lower salt consumption involving specific settings and using existing infrastructures such as schools, workplaces and community centres, and (v) monetary support for industries and researchers in the effort to reduce salt levels in salty foods.

However, there are several limitations, including that some of the policy-makers at the state level were not involved, and the online sessions conducted during the COVID-19 pandemic could have been better conducted face to face to obtain a better insight from the participants. Further research could focus on the effectiveness of current strategies such as Healthy Choice logos, toward a salt reduction strategy, and also innovative techniques to reduce salt in salty foods commonly consumed by the population.

Conclusions

Perceptions on the salt reduction policy in Malaysia among policy-makers and the food industries were positive as they believe the policy could reduce the salt intake among the population and prevent noncommunicable diseases, particularly hypertension and cardiovascular diseases. Several challenges in implementing the salt reduction policy including acceptance by consumers of reduced salt foods, lack of knowledge and behavioural changes exist and can be addressed by education and continuous awareness campaigns. An absence of standards and guidelines for reformulations poses a challenge to producing lower salt food products. Priority issues and lack of support are other barriers that could prevent the success of the salt reduction policy. Hence, it is important to set a salt reduction target, encourage researchers to venture into research on salt reduction and engage the food industries to start with voluntary reformulation to reduce salt content in foods. Financial support is needed for research and reformulation, product development, use of possible technologies in food processing and to conduct bigger salt reduction campaigns. In summary, the salt reduction policy needs to involve all parties. Collaboration among ministries, researchers, nongovernmental organizations and the food industry is vital to make sure the policy that has been outlined by the Ministry of Health could effectively reach the global salt reduction target.