An estimated 8 million people in Thailand suffer from chronic kidney disease, according to 2017 statistics from the Ministry of Public Health. Of this number, around 100,000 patients are in the terminal stage and require haemodialysis on a regular basis, which works as an artificial kidney. This requires a national budget of over 20 billion baht per year.
If nothing is done, the number of end-stage kidney patients in Thailand will hit 200,000 by 2022, which would cost 40 billion baht annually.
After Thailand enacted an excise tax on sugary drinks two years ago, it's time for the country's public health authority to shine the spotlight on sodium -- another silent killer responsible for illnesses such as chronic kidney disease and hypertension.
As part of efforts to promote the consumption of healthy food and to cut the amount of sodium in diets, the Excise Department announced earlier this month that it is inching towards the introduction of new taxes on salty, processed food. While details are now being sorted out through discussions with the Food and Drug Administration (FDA) and other relevant parties, it is expected that the tax conditions can be finalised by the end of this year before being submitted to the finance minister for consideration.
According to the Excise Department, the new tax on salty foods will work in a straightforward manner -- the higher the sodium content, the higher the tax. The new tax policy will target instant noodles, frozen products and canned foods. Seasonings and condiments such as fish sauce, soy sauce and salt will be exempt. Manufacturers are expected to get a reprieve of one to two years to give them time to adjust and reduce the amount of sodium in their products.
When it comes to the consumption of salt and sodium, the Thai authority has a sound reason to be worried. Based on the World Health Organization's (WHO) daily recommendation, daily sodium intake is capped at 2,000mg. The average Thai, however, consumes up to 4,200 to 4,300mg of sodium on a daily basis -- around 2.2 times the WHO's threshold.
"The figure of 2,000mg as set by the WHO is not even the amount that the body requires. Rather it is the Tolerable Upper Intake Level which means the highest level of daily intake that is likely to pose no risk of adverse health effects. In fact, the body only requires around 1,200 to 1,500mg of sodium per day," said Assoc Prof Wantanee Kriengsinyos of Mahidol University's Institute of Nutrition.
This also means an average Thai consumes around three times the body's daily requirement of sodium.
Along with the WHO's target to lower the amount of daily sodium intake by 30% by 2025, Thailand has constantly campaigned against the overconsumption of salt and sodium with little evidence of progress. One indicator is the prevalence of hypertension in the country. According to the Bureau of Non-Communicable Diseases under the Ministry of Public Health's Department of Disease Control, hypertension is still a huge public health concern. In 2013, approximately 4 million Thais were diagnosed with high blood pressure. In 2018, the number rose to 6 million.
The number of hypertension-related deaths also skyrocketed too -- from around 5,100 deaths in 2013 to over 8,500 deaths in 2017.
"This somehow suggests Thai consumers are not careful enough when it comes to eating," commented Wantanee, also programme director of the Master of Science Programme in Nutrition and Dietetics under Mahidol University's Institute of Nutrition.
Foods that contain sodium are not necessarily salty, explained the nutrition expert. Foods that are salty apparently contain a high level of sodium through seasoning and condiments. Salt, for instance, contains 40% sodium (and 60% chloride) while monosodium glutamate (MSG) contains only 15% sodium.
Apart from seasoning, sodium is used as a food additive and preservative in such local treats as salted eggs and fish to prolong shelf life. Processed foods including sausages, kun chiang (Chinese sausage) and moo yor (white pork sausage) are also full of sodium.
"When you taste these products, the salty flavour doesn't really stand out but they still contain sodium as a food additive," added Wantanee. "If we compare pork and sausage, we will see that 30g of pork contains around 30mg of sodium while the same amount of sausage can contain up to 240mg of sodium."
Bakery industries also use a lot of sodium such as sodium bicarbonate in baking powder. A serving spoon of cooked rice contains around 20mg of sodium while a slice of bread contains up to 130mg of sodium.
"We have to be vigilant towards such hidden sodium too," Wantanee warned.
The new tax is targeting instant noodles, which are obviously high in sodium. Wantanee also warned that most street food can be as sodium-rich as instant noodles.
"A bowl of duck noodles can contain up to 2,000 to 2,300mg of sodium, for instance," she added. "These street foods might not be subject to compliance to any clear-cut measures. Monitoring and creating awareness among these vendors might not be a piece of cake either. Several studies have found a lot of [street food] vendors add a large amount of seasoning powder. The same thing happens in household kitchens."
While the new sodium tax can potentially be of help to a certain extent, Wantanee believes that its effectiveness would vary according to consumers' eating behaviours. For those who rely much on industry-scale food such as frozen foods and instant noodles from convenience stores and supermarkets, the new tax will affect them for certain. But for those who buy fresh food from markets, for instance, or eat in food courts, the new levy might not cause their eating behaviours and overall diets to change unless they become aware of the perils of sodium overconsumption.
So apart from the soon-to-be-implemented tax protocol, Wantanee suggested campaigns should focus on positive reinforcement ideology so that consumers feel the urge to change from the inside rather than being compelled.
"Workplaces should be encouraged to make a healthy eating environment as well as to create more awareness among consumers regarding healthy eating habits in a nice manner instead of forcing them to change. A healthy canteen where a list of healthy dishes are available and promoted alongside regular menus should be set up so that staff realise they have healthier alternatives too. At a condiment corner, cute tags with lovely images and text encouraging them to cut the amount of sodium, for example, can be attached to the fish sauce or soy sauce bowl. Or providing staff with a smaller fish sauce spoon might help."
"When consumers get used to something, of course it's not easy to change," Wantanee concluded. "But if every party involved plays their part in helping and raising awareness, change is definitely possible."
