Salt     Worldwide Action           Graham A MacGregor    Professor of Cardiovascular Medicine            Chairman of WASH...
Salt Reduction            WHY?• Salt is the major cause of raised BP (Biggest cause of death)• Very cost-effective to impl...
Major Underlying Factors causing Death - WorldwideRaised Blood Pressure                                       7 million   ...
Systolic BP and Risk of Death            Stroke Deaths                         Heart Deaths       32                      ...
Brain (cross section)   Mid line shift due to                          raised pressure                          Cerebral  ...
Atheroma in Carotid Artery          Plaque                         Ulcerated                          Plaque              ...
Salt   Up to 5000 yrs ago 0.1 g/d, now 9 to 12 g/d                       Why?               (a) Preserves food            ...
Evidence• Epidemiology        Over 50 population studies and Intersalt• Migration           e.g. Kenya• Intervention      ...
Meta-analysis of ↓ Salt Intake by           5-6 g/day  ↓ Stroke 24%           ↓ CHD 18% UK              ≈35,000 deaths pre...
Meta-analysis of Outcome Trials (Lancet 2011)               ↓ Salt 2 g/d      ↓ CVD events 20% (P<0.05)                   ...
SummarySalt intake (9–12 g/day) • Population BP, rise in BP with age, hypertension • Other effects e.g. stomach cancer, st...
How to ↓ salt intake1. Measure salt intake – 24h urine   Spot urine may be used to follow   subsequent reduction2. Sources...
How to ↓ salt intake (e.g. 10→5 g/d)              Develop    strategic plan to reduce salt        Added              Food ...
CASH Strategy for Reducing Salt in UK               Salt intake           Reduction        Target intake                  ...
How to ↓ Salt - Food Industry• Voluntary                        Set targets• Regulatory            for food               ...
Hiddenfast, takeaway, restaurant foode.g. processed,                Salt in Food      Food industry slowly reduce        -...
Salt reduction targetsA level playing field - all companies work          to the same salt target
Voluntary                   Regulation/legislationQuicker                       SlowerContinuous media              No nee...
The voluntary ‘carrot and stick’          approach        food      industry                            www.actiononsalt.o...
UK Success by 2011     Salt intake has been reduced  from 9.5 to 8.1 g/d salt (15% ↓)       i.e. 49,000 tons/yr salt remov...
UK Success 2011• Processed food products ↓20-50%  1. No taste problems  2. No technical problems• Food outside home now be...
Cost-effective Analysis            UK (NICE)Cost of salt campaign ≈£5 million per yearHealthcare savings ≈ £1.5 billion pe...
WASH Action Groups                     www.worldactiononsalt.com
USA• Target for 50% of the population - 1500 mgsodium (IOM)• Current intake ≈3600 mg/d• ≈60% reduction required by food in...
South Africa• Has set target of 5 g/d salt by 2025• Minister of Health can regulate food supply• 29 out of 30 major global...
Worldwide                          Action     1.   USA, Canada, Australia following UK model     2.   Europe (ESAN) 16% re...
Salt - SummaryEvery country in the world must now   1. Set up salt reduction plan   2. Implement the plan       This is th...
Salt Worldwide Action
Salt Worldwide Action
Salt Worldwide Action
Salt Worldwide Action
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Salt Worldwide Action

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  • 75% salt is in processed foods The first set of salt targets were published in March 2006. They covered 85 categories of processed foods that contribute most salt to the diet, including staple food such as bread, bacon, breakfast cereals, cheese, etc. Out of home and catering sector wrongly left out Reset for 2012 Monitor reductions in the amount of salt added to the food by the food industry and ensure that they will reach the target that has been set for them These would be closely monitored and independently checked by the FSA, as well as surveys by CASH.
  • The follow up with M&amp;S and EAT. Who are reviewing their products
  • Salt Worldwide Action

    1. 1. Salt Worldwide Action Graham A MacGregor Professor of Cardiovascular Medicine Chairman of WASH Wolfson Institute of Preventive Medicine,Barts and The London School of Medicine & Dentistry, Queen Mary University of London, UK
    2. 2. Salt Reduction WHY?• Salt is the major cause of raised BP (Biggest cause of death)• Very cost-effective to implement
    3. 3. Major Underlying Factors causing Death - WorldwideRaised 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.
    4. 4. Systolic BP and Risk of Death Stroke Deaths Heart Deaths 32 16 16 8 8 4Risk Risk 4 2 2 1 120 125 135 148 168 120 125 135 148 168 Systolic Blood Pressure (mmHg) The risk starts in the normal range at systolic 115 mmHg (83% adults) MacMahon et al. Lancet 1990;335:765-74
    5. 5. Brain (cross section) Mid line shift due to raised pressure Cerebral haemorrhage
    6. 6. Atheroma in Carotid Artery Plaque Ulcerated Plaque Fissured Plaque with Thrombosis
    7. 7. Salt Up to 5000 yrs ago 0.1 g/d, now 9 to 12 g/d Why? (a) Preserves food (b) Cleans up bad food Now no need (a) Refrigeration (b) Better chemicalsBut eating 9 to 12 g/d - courtesy of the food industry Processed Fast 80% of salt hidden in food Restaurant Canteen Salt, diet & health. 1998, Camb Uni Press
    8. 8. Evidence• Epidemiology Over 50 population studies and Intersalt• Migration e.g. Kenya• Intervention Portuguese 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)• Treatment Meta-analysis. Dose response• Mortality studies Meta-analysis of cohort studies• Outcome trials Meta-analysis of outcome trials
    9. 9. Meta-analysis of ↓ Salt Intake by 5-6 g/day ↓ Stroke 24% ↓ CHD 18% UK ≈35,000 deaths prevented per year Worldwide ≈ 2.5 million deaths prevented per year He & MacGregor. Hypertension 2003;42:1093-99
    10. 10. Meta-analysis of Outcome Trials (Lancet 2011) ↓ Salt 2 g/d ↓ CVD events 20% (P<0.05) He & MacGregor. Lancet 2011;378:380- 382
    11. 11. SummarySalt intake (9–12 g/day) • Population BP, rise in BP with age, hypertension • Other effects e.g. stomach cancer, stroke, LVH, kidney disease, osteoporosis etc ∴ Reduce salt intakefrom 9–12 g/day to 5 g/day
    12. 12. How to ↓ salt intake1. Measure salt intake – 24h urine Spot urine may be used to follow subsequent reduction2. Sources of salt – dietary record or recall3. Work out major sources of salt in the diet4. Develop strategic plan
    13. 13. How to ↓ salt intake (e.g. 10→5 g/d) Develop strategic plan to reduce salt Added Food industry • Cooking/Table • Processed food • Other sources of • Eating out, e.g. fast food, canteen salt, e.g. stock cube, table sauces, etc • Set targets 50%↓ 50%↓
    14. 14. CASH Strategy for Reducing Salt in UK Salt intake Reduction Target intake needed g/day Source g/dayTable/Cooking (15%) 1.4 g 40% reduction 0.9 gNatural (5%) 0.5 g No reduction 0.5 gFood industry (80%) 7.6 g 40% reduction 4.6 g Total 9.5 g Target 6.0 g∴ The food industry needs to slowly reduce saltcontent of all foods by 40% over the next 5 yearsby setting target for each food category www.actiononsalt.org.uk
    15. 15. How to ↓ Salt - Food Industry• Voluntary Set targets• Regulatory for food categories, e.g. in 5 yrs• Legislation• Salt tax on label (raises revenue)
    16. 16. Hiddenfast, takeaway, restaurant foode.g. processed, Salt in Food Food industry slowly reduce - No rejection by public Fantastic for Public Health Very little No need to cost ↓ BP change diet www.worldactiononsalt.com
    17. 17. Salt reduction targetsA level playing field - all companies work to the same salt target
    18. 18. Voluntary Regulation/legislationQuicker SlowerContinuous media No need for media pressure pressureAcceptable to Party in power may government changeBig reduction - difficult Big reduction - possibleFood industry needs “level playing field”
    19. 19. The voluntary ‘carrot and stick’ approach food industry www.actiononsalt.org.uk
    20. 20. UK Success by 2011 Salt intake has been reduced from 9.5 to 8.1 g/d salt (15% ↓) i.e. 49,000 tons/yr salt removed≈ 18000 strokes & heart attacks prevented per year (9,000 fatal) www.actiononsalt.org.uk
    21. 21. UK Success 2011• Processed food products ↓20-50% 1. No taste problems 2. No technical problems• Food outside home now being tackled• Table and cooking salt sales ↓40-50%Salt intake should reach less than 6 g/d target around 2016 (i.e. within 10 yrs) www.actiononsalt.org.uk
    22. 22. Cost-effective Analysis UK (NICE)Cost of salt campaign ≈£5 million per yearHealthcare savings ≈ £1.5 billion per year http://guidance.nice.org.uk/PH25
    23. 23. WASH Action Groups www.worldactiononsalt.com
    24. 24. USA• Target for 50% of the population - 1500 mgsodium (IOM)• Current intake ≈3600 mg/d• ≈60% reduction required by food industry• This will require legislation to ensure a levelplaying field• Start now with a voluntary policy whilstlegislation is enacted
    25. 25. South Africa• Has set target of 5 g/d salt by 2025• Minister of Health can regulate food supply• 29 out of 30 major global food companiesopted for a regulatory approach as it gavethem a guarantee of a level playing field• Salt targets for individual food groupscurrently being set
    26. 26. Worldwide Action 1. USA, Canada, Australia following UK model 2. Europe (ESAN) 16% reduction over 4 yrs 3. PAHO: Brazil sets targets, Chile, Argentina, Mexico following 4. Asian-Pacific: Salt intake is very high, e.g. China, Japan, Korea. Urgent need to reduce salt 5. Arab world & middle-east – No action as yetGlobal Food Industry could play a much more prominent role • Unilever & Pepsico worldwide salt reduction across their products • Kellogg’s, Nestle about to reduce salt globally to UK levels www.worldactiononsalt.com
    27. 27. Salt - SummaryEvery country in the world must now 1. Set up salt reduction plan 2. Implement the plan This is the single mostcost-effective public health measure It would be negligent for any government not to take action now www.worldactiononsalt.com

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