Global Salt Initiatives From Evidence to Worldwide Implementation

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Global Salt InitiativesFrom Evidence to
Worldwide Implementation

• Graham A MacGregor

worldactiononsalt.com
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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 20023601347-60.
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Systolic BP and Risk of Death
Heart Deaths
Stroke Deaths
16
32
16
8
4
8
Risk
Risk
2
4
1
2
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 1990335765-74
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Atheroma in carotid artery
Plaque
Ulcerated Plaque
Fissured Plaque with Thrombosis
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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.
doi10.1038/jhh.2008.144.
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Salt
Up to 5000 yrs ago 0.1 g/d, now 10 to 12 g/d
Preserves food
(a)
Why?
Cleans up bad food
(b)

• Refrigeration
• Better chemicals

Now no need
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
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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 Trials, 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.
doi10.1038/jhh.2008.144.
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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
Plt0.001 reduced salt vs. usual salt intake.

He MacGregor. JHH 200216761-770
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? salt intake 6g/day
? Avg. 5 mmHg
? Stroke 24
? CHD 18

• USA
• 150,000 (approx) deaths prevented / year
• Worldwide
• 2.5 million (approx) Stroke Heart attack deaths
  prevented / year

He MacGregor. Hypertension 2003421093-99
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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 lt 5g/day)
WHO/FAO 2002. www.who.int/hpr/NPH/docs/who_fao_exp
erts_report.pdf
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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. 19871426-429.
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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.
doi10.1038/jhh.2008.144.
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Sea Water Comparison (1.0 g of sodium / 2.5g of
salt per 100g)

• 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

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 C
ornflakes 110 Tomato Ketchup 110 Brown
Sauce 100
Most have now been reduced by 10 30 (2008) in
the UK
Above data collected 2001
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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.
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Finland
Salt intake (g/day)
Diastolic BP (mmHg)
Stroke mortality (1/100000)
Men
Men
Women
Women
Year
Year
Year
Karppanen Mervaala. Prog Cardiovasc Dis
20064959-75.
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Action in the UKConsensus Action on Salt Health

• Members all experts on salt and BP
• Set up 1996 in response to rejection of salt
  reduction recommendations by UK Dept. of Health

Aims
?

• 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 companys to reduce
  salt added to food

?
?
?
www.actiononsalt.org.uk
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CASH Strategy for Reducing Salt in UK
Salt intake
Target intake g/day
Reduction needed
Source
g/day
Table/Cooking (15)
0.9 g
40 reduction
1.4 g
Natural (5)
0.5 g
No reduction
0.5 g
Food industry (80)
4.6 g
40 reduction
7.6 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.
doi10.1038/jhh.2008.144.
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Sun newspaper 05/08/2004
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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
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www.salt.gov.uk
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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
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Traffic Light Label
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GDA Label
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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.
doi10.1038/jhh.2008.144.
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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 2003421093-99
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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
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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
• Kelloggs Rice Krispies
• (Sodium (mg) /100g) 667 821 650 720

Source Product websites 2009
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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/ma
in/WHO/Progs/NUT/ActionPlan/20080516_1
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Examples of actions in other countries

• Australia AWASHs 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
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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
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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. doi10.1038/jhh.2008.144.