Table 4 Contextual factors affecting intervention design, delivery and outcomes

Policy environment

Healthy Food Partnership’s slow progress towards setting draft sodium targets

I feel like the advocacy activities probably have just added a strong supporter base around things that were in-train. A reformulation programme was being discussed, being designed, being consulted on. We could then put Partnership responses in, the technical response that The George Institute put in, or just put the weight behind it – we need it fast, we need it to be a really comprehensive programme. (Member 11: SP, I, R)

I think we’ve certainly affected things that have been going on. The Healthy Food Partnership was there, and we were able to offer commentary whenever we were asked, we offered support and we will continue... to kind of push that reformulation story with government. So, whilst we might not have seen policy change, we’ve definitely continued the conversation and put support behind it, extra support behind it when we’ve been asked. (Member 21: SP, I)

It was challenging to get engagement because the food companies were waiting to find out what the salt reduction targets were going to be… the Heart Foundation, with our support, manages to identify a program of work to engage industry at the same time as waiting for the targets. (Member 2: SP, I, R)

Obviously, the lag on the targets for the Healthy Food Partnership being set has been a bit disappointing and obviously that’s outside the control of the group. Once those are in place you would think that that may heighten the activity of the food industry and manufacturers to reformulate and help to reach that outcome but again that’s still a while away. (Member 1: SP, R)

Alignment with state nutrition policies/ strategies (e.g. Healthy Choices)

I don’t think [salt] is necessarily embedded in strategy at [state] government level... there’s a few individuals that have really driven it and championed it which has been fantastic, but whether that’s embedded in the strategy if they were to leave, I’m still not sure. (Member 7: SP)

In relation to the state-wide policies on food in institutional settings, it’s been a challenge to impact on those processes and also to know whether or not those policies are being implemented and whether or not they are also incorporating salt in those policies...we didn’t have any direct access to those institutional settings. (Member 2: SP, I, R)

Political climate

Salt is not a current government priority

There’s been some good work but as a whole probably hasn’t quite had the impact at the state and federal level as we would have wanted, and that’s not necessarily because of the fault of any of the partners, it’s partly because of the political conversations and agendas out where salt is and you can’t make an issue popular with politicians if they don’t want it to be and there’s not a public push... so the politicians have been able to kind of ignore it. (Member 10: SP)

We obviously wanted policy change. We have had a government in ... it’s not the highest thing on their priority list. (Member 21: SP, I)

Lack of policy window in the intervention time period

It would have to do with the fact that what we’re trying to do was trying to move a mountain and that’s a very difficult thing to do when you’re just a group of mountaineers... The reality is it’s still a priority, it needs to be a priority and like in tobacco control or any other public health area, often it can take twenty or thirty years for the advocacy really to reach a critical mass and then find a sympathetic minister or a sympathetic government or a sympathetic community and the timing is right and suddenly you get an opportunity… A lot of success of public health has time to build and a long time to make the business case, and then the policy window opens, and that’s the opportunity there. (Member 13: SP)

Sometimes you’ve just got to go with what the political climate’s going to let you do, and both with industry and politicians and sometimes it’s not your day or year or your decade and you can’t change everything unfortunately. (Member 10: SP)

Social factors

Crowded nutrition space

The reality is that the broad community debate on these issues have usually been dominated by issues of a sugar tax or health levy on sugary drinks and the role of sugar as a driver of the obesity epidemic in recent years, and I think to that extent the Partnership and the salt focus was always going to struggle to get cut through, but it doesn’t mean that it’s a failure, it just means that it’s a competitive environment for community engagement on food and I think there’s been some good progress made by the Partnership in general community awareness, engaging with the industry, engagement with policy makers as well but that’s against the backdrop of broadly a lack of recognition of salt as a population health priority in the Australian context. (Member 13: SP)

Sugar was much more of a top of mind issue for many, particularly consumers, but also for industry and even government to some degree, or the political end of the spectrum. (Member 7: SP)

Perceived value of a single nutrient approach

Not everyone in Victoria, and in Victoria healthy eating sector, would support a salt reduction approach... nutrient-specific projects are not really what they’re at the moment, prioritising. (Member 11: SP, I, R)

I’ve always been a very strong internal advocate in the food and nutrition space and particularly around the need for a focus on salt reduction and it has been one issue that really was becoming a little problematic was this broader issue that’s run by nutritionists, in general, dietitians I should say, about the fact that we shouldn’t focus on single nutrients. (Member 8: SP)

Environmental factors

The broader food environment

Everyone in Australia gets 70% of their salt or 80% of their salt from packaged foods and restaurant foods. (Member 4: SP, R)

Technological factors

Technology as a barrier to reformulation

Barriers are taste, technology is to do it... consumer acceptance, quality because salt provides a technical role, not just boosting flavours, though that’s definitely a factor. (Industry 17)

There are things that we can do and there are things that we can’t do... also the implications of reformulation, what do we replace it with, if anything, and is that more or less harmful than the original. From our perspective if we ask the food industry to reformulate in a short period of time, they can only use the technology that’s available to them, but you know doesn’t give them time to look for other options and you may get a food supply flooded with things that you don’t want. And that’s what we are very mindful of and we’re very concerned... we try not to put other things in that may not be necessarily a better option. (Industry 18)

We also have joint research programs... to try and use different technologies so we can get the sodium down but still have a good taste. (Industry 19)

Other factors affecting the food industry’s ability to reformulate

Functional role of salt in food

In many cases, especially in extrusion and in other types of crisping, there’s only so much you can take out before the product no longer resembles its form. (Industry 18)

In some other industries... you need salt for a functional benefit, and also in some of the products we do like crackers where sodium bicarbonate is used as a raising agent, it’s sometimes very hard then to get products low in acid sodium. Sodium can be used either alone or in combination with other things like sodium bicarbonate, like a functional base, like a raising agent. (Industry 19)

There is a sweet spot where manufacturers can take out small amounts of sodium without too negatively affecting taste and function, and I think responsible food producers are working towards achieving that. In order to go further, which is really becoming creative with ingredients and flavours and so on to reduce the sodium, but still maintain terrifically tasty products for consumers... If they don’t have the food science product development teams to work with ingredients and flavours and so on to produce outstanding products with taste, with low sodium... what they will need is possibly assistance or direction with, and exposure to a skillset and information that will allow them to explore product development and reformulation at low sodium target levels. (Industry 14)

Feasibility of removing salt from food

In the company’s that I have worked for or consulted to, they have literally just removed the sodium because their products aren’t very complicated, they haven’t had to look for alternatives. (Industry 16)

The thing with salt is that it’s easier to remove and replace salt than it is to remove and replace sugar. So, it is something that you can do by stealth and train the palate slowly to get used to. And because there is very little bulk in salt it’s just easier to take out than some of the other ingredients. (Industry 18)

Skills and expertise to reformulate

Understanding that some, especially the smaller manufacturers, might need some skilled food science and product development help in reformulating lower sodium, but still maintaining amazing mouth feel and taste. (Industry 14)

Companies now employing dietitians and registered nutritionists. That’s important that they acknowledge that they need that level of expertise and science within their company to help guide them, to help guide their leadership team to what they should be doing from a health perspective. (Industry 17)

The big players are the ones who are doing a lot in that space because they’ve got the resource, like we’ve got a dedicated nutrition team, a dedicated regulatory team, a sustainability nutrition team, we’ve got the resources. Whereas I know the smaller businesses don’t and they need to see what we’re doing, and they need to learn from us. (Industry 17)

There’s a huge gap in resources and huge gaps in capabilities. Even the large manufacturers who we naively thought had the capabilities do not have well-resourced nutrition units within their organisations. (Member 6: I)

Cost of reformulating

I think cost is a massive issue. Buying salt replacements is more expensive than putting salt in and it’s just how willing people are to be able to take a hit on growth margins, and if you do it slowly by stealth then you’re in a better position. (Industry 18)

Every single reformulation that you do requires a project, requires resources, requires trial time, requires trial managing, requires package changes, it’s a very expensive exercise. (Industry 18)

Salt is a cheap ingredient and it can be that as we reduce salt, the costs go up. (Industry 2)