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Global Salt Initiatives From Evidence to Worldwide Implementation

Global Salt Initiatives From Evidence to Worldwide Implementation. Graham A MacGregor. worldactiononsalt.com. Major Underlying Factors Causing Death - Worldwide. Raised Blood Pressure. 7 million. Tobacco. Developed region. High cholesterol. Developing region. Underweight. Unsafe sex.

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Global Salt Initiatives From Evidence to Worldwide Implementation

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  1. Global Salt InitiativesFrom Evidence to Worldwide Implementation Graham A MacGregor worldactiononsalt.com

  2. Major Underlying Factors Causing Death - Worldwide Raised Blood Pressure 7 million Tobacco Developed region High cholesterol Developing region Underweight Unsafe sex 0 1 2 3 4 5 6 7 Millions of Deaths Raised BP is responsible for 62% of all Strokes & 49% of all Heart Disease Ezzati et al. Lancet 2002:360:1347-60.

  3. Systolic BP and Risk of Death Stroke Deaths Heart Deaths 32 16 16 8 8 4 Risk Risk 2 4 2 1 120 125 135 148 168 120 125 135 148 168 Systolic Blood Pressure (mmHg) The risk starts at systolic 115 mmHg (83% adults) MacMahon et al. Lancet 1990;335:765-74

  4. Atheroma in carotid artery Plaque Ulcerated Plaque Fissured Plaque with Thrombosis

  5. What puts up population BP? • Salt intake • Lack of fruit and vegetables • Weight • Lack of exercise • (Alcohol excess) He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

  6. Processed Fast Restaurant Canteen Salt Up to 5000 yrs ago 0.1 g/d, now 10 to 12 g/d Preserves food (a) Why? (b) Cleans up bad food Now no need • Refrigeration • Better chemicals But eating 10 to 12 g/d - courtesy of the food industry 80% of salt hidden in food Salt, diet & health. 1998, Camb Uni Press

  7. Evidence • Epidemiology Over 50 population studies and Intersalt • Migration e.g. Kenya • InterventionPortuguese villages. New born babies • Genetic All defects impair ability of the kidney to excrete Na • Mechanisms Plasma Na, corrected volume expansion • Animal BP caused or aggravated by salt (e.g. chimpanzees) • TreatmentTrials, Meta-analysis. Dose response • Mortality studies Finland (24h UNa) • Outcome trials TOHP, Taiwan (mineral salt: high K, low Na) He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

  8. Meta-analysis of Modest Salt Reduction Trials of one month or Longer Hypertensive Normotensive 0 -2 Fall in Systolic BP (mmHg) *** -4 *** -6 150 Urinary Sodium (mmol/24h) 100 Usual salt intake 50 0 Reduced salt intake P<0.001 reduced salt vs. usual salt intake. *** He & MacGregor. JHH 2002;16:761-770

  9.  salt intake 6g/day Avg. 5 mmHg • USA • 150,000 (approx) deaths prevented / year • Worldwide • 2.5 million (approx) Stroke & Heart attack deaths prevented / year Stroke24%  CHD 18% He & MacGregor. Hypertension 2003;42:1093-99

  10. Summary Salt intake (10 – 12 g/day) • Population BP, rise in BP with age, hypertension • Other effects e.g. stomach cancer, stroke, LVH, kidney disease, osteoporosis etc Reduce salt intake • From 10 - 12 g/day to 5 - 6g/day (WHO target < 5g/day) WHO/FAO 2002. www.who.int/hpr/NPH/docs/who_fao_experts_report.pdf

  11. Consumers have little or no choice over their salt consumption Current salt intake & sources of salt in UK (Similar in USA) Table / Cooking (15%) 1.4 g/d Natural (5%) 0.5 g/d Food industry (80%) 7.6 g/d Total 9.5 g/d (3.8 g sodium) Why is there so much salt in processed food? James et al. Lancet. 1987;1:426-429.

  12. Hidden Salt – Its Commercial Value SALT Profit Producers (40% by value) Food Industry Highly Salted Processed Food Meat products ­ + Salt Dependence on salty taste (Salt Addiction) Salt­ Water Binding ­ Salt ­ Salt­ Thirst ­ Demand for very salty foods ­ Weight ­ No Cost Soft Drinks Mineral Water ­ Profit Profit Profit He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

  13. Sea Water Comparison (1.0 g of sodium / 2.5g of salt per 100g) Medium Sliced White 50% Granary Loaf 60% Crumpets 80% Digestive 60% Cream Crackers 60% Cheddar Cheese 70% Stilton Cheese 90% Processed Cheese 130% Branflakes 100% Cornflakes 110% Tomato Ketchup 110% Brown Sauce 100% Pizza 60% Chicken Curry 60% Processed Cheese 130% Bacon 200% Sausages 100% Smoked Fish 190% Sweet Pickle 170% Shepherds Pie 40% Frozen Prawns 80% Crisps 110% Salad Cream 100% Savoury Biscuits 70% Most have now been reduced by 10 – 30% (2008) in the UK Above data collected 2001

  14. Japan 1960 Government campaign to reduce salt intake Overall: 13.5 → 12.1 g/day (1.4 g/day ↓) Akita (North): 18 → 14 g/day (4 g/day ↓ ) BP  80%  in stroke mortality At this time Japan rapidly Westernised e.g. saturated fat, smoking,  weight,  exercise Sasaki N. The salt factor in apoplexy and hypertension: epidemiological studies in Japan. In: Yamori Y, editor. Prophylactic Approach to Hypertensive Diseases. New York: Raven Press; 1979. p. 467-74.

  15. Finland Salt intake (g/day) Stroke mortality (1/100000) Diastolic BP (mmHg) Men Men Women Women Year Year Year Karppanen & Mervaala. Prog Cardiovasc Dis 2006;49:59-75.

  16. Action in the UKConsensus Action on Salt & Health • Change Department of Health policy • Ensure Food Standards Agency adopted salt reduction & labeling • Media publicity to the public and food industry • Persuade retailers and food company’s to reduce salt added to food • Members all experts on salt and BP • Set up 1996 in response to rejection of salt reduction recommendations by UK Dept. of Health Aims     www.actiononsalt.org.uk

  17. CASH Strategy for Reducing Salt in UK Salt intake Target intake g/day Reduction needed Source g/day 40% reduction Table/Cooking (15%) 1.4 g 0.9 g No reduction Natural (5%) 0.5 g 0.5 g 40% reduction Food industry (80%) 7.6 g 4.6 g Total 9.5 g Target 6.0 g  the food industry needs to reduce salt content of all foods by 40% over the next 5 years He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

  18. Sun newspaper 05/08/2004

  19. Food Standards Agency (UK) • Set up to deal with BSE – New variant CJD • What else? – salt reduction • Gradual repeated reductions in salt added to foods by 15%-25% • Processed foods divided into 80 categories with targets set to be reached by the food industry in 2010 and 2012. • Aim: To reduce salt intake to less than 6 g/d (adults) by 2012 www.food.gov.uk

  20. www.salt.gov.uk

  21. Target set for levels of salt in key product categories 2006 Revised targets to be achieved by 2012 0.93g salt (370mg sodium) per 100g (avg) www.food.gov.uk

  22. Traffic Light Label

  23. GDA Label

  24. Actions so far • Most processed foods have or will be reduced by 20-30% by 2010 • More challenging targets have been set to be achieved by 2012 • Foods eaten outside the home are now being addressed (e.g. canteens, restaurants, fast foods, takeaways, etc.) • Aim: To reduce salt intake to less than 6 g/d (adults) by 2012 He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

  25. Success so far UK 24h urinary sodium in a random sample of adult population has been reduced from the start of the program in 2003 to 2008 from 9.5 to 8.6 g/d of salt (10% ) www.food.gov.uk (NB: on the background of an increasing salt intake) Approx. 6000 deaths - strokes, CHD prevented / yr He & MacGregor. Hypertension 2003;42:1093-99

  26. World Action on Salt & Health 366 members from 80 countries worldwide • Worldwide • Highlight foods high in salt • Implement salt reduction • Clear labeling system (traffic light) • Individual countries • Facilitate expert groups similar to CASH • Convince government and health dept. & ensure action by food industry • Public health campaign to  salt consumption Target:  Salt intake worldwide to 5g/d (WHO) www.worldactiononsalt.com

  27. Example sodium content around the world USA Canada UK Australia • McDonalds ‘Big Mac’ (Sodium (mg) per portion) 1,040 1,020 840 960 • Subway ‘Italian BMT Sub’ (Sodium (mg) per portion) 1,770 1,670 1,700 1,470 • KFC ‘Fillet Burger’ (Sodium (mg) per portion) 1,230 1,250 1,200 1,265 • Kellogg’s ‘Rice Krispies’ (Sodium (mg) /100g) 667 821 650 720 Source: Product websites 2009

  28. WHO and EU Actions WHO set up a Salt Action Network (SAN) • To implement the EU framework for National Salt Initiatives • The goal →↓ salt intake less than 5 g/day • Initial activity - 12 food categories, e.g. bread, ready meals, breakfast cereals • 24 countries now pledged to make a 16% salt reduction over 4 yrs WHO Europe. http://test.cp.euro.who.int/eprise/main/WHO/Progs/NUT/ActionPlan/20080516_1

  29. Examples of actions in other countries • Australia AWASH’s Public Health campaign starting to show results • Bangladesh National reduction supported by the National Heart Foundation • Bulgaria Monitoring and evaluating programme for salt reduction initiatives • Canada The Canadian Stroke Network has a full scale public health campaign • Croatia CRASH: full national awareness campaign • Kenya Forming a Kenyan arm on WASH following a successful campaign • Malta Launched a salt reduction initiative • USA Have had strong recommendations since 1980s, with no results • Salt Institute opposed any action (similar to Tobacco Manufactures Association) • FDA Petition for salt as ‘Generally recognised as safe’ to an ‘additive’ has so far proved ineffective www.worldactiononsalt.com

  30. Participating country World Salt Awareness Week 2009 Activities ranged from involvement from hypertension experts, representatives from the health and education ministries, consumers, the media and the food industry. Participation from 28 countries around the world

  31. Summary Stroke Heart Attacks Heart Failure • Salt intake BP •  Salt intake biggest improvement in public health since clean water and drains (19th Century) Stomach Cancer & Osteoporosis He & MacGregor. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.

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