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. Salt Reduction
WHY?
• Salt is the major cause of raised BP
(Biggest cause of death)
• Very cost-effective to implement
3. 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.
4. Systolic BP and Risk of Death
Stroke Deaths Heart Deaths
32 16
16 8
8 4
Risk 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
6. Atheroma in Carotid Artery
Plaque
Ulcerated
Plaque
Fissured Plaque
with Thrombosis
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 chemicals
But 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. 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. 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. 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. Summary
Salt 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 intake
from 9–12 g/day to 5 g/day
12. How to ↓ salt intake
1. Measure salt intake – 24h urine
Spot urine may be used to follow
subsequent reduction
2. Sources of salt – dietary record or
recall
3. Work out major sources of salt in the
diet
4. Develop strategic plan
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. CASH Strategy for Reducing Salt in UK
Salt intake Reduction Target intake
needed g/day
Source g/day
Table/Cooking (15%) 1.4 g 40% reduction 0.9 g
Natural (5%) 0.5 g No reduction 0.5 g
Food 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 salt
content of all foods by 40% over the next 5 years
by setting target for each food category www.actiononsalt.org.uk
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. Hiddenfast, takeaway, restaurant food
e.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
18. Voluntary Regulation/legislation
Quicker Slower
Continuous media No need for media
pressure pressure
Acceptable to Party in power may
government change
Big reduction - difficult Big reduction - possible
Food industry needs “level playing field”
22. 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
23.
24. 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
25. Cost-effective Analysis
UK (NICE)
Cost of salt campaign ≈£5 million per year
Healthcare savings ≈ £1.5 billion per year
http://guidance.nice.org.uk/PH25
28. USA
• Target for 50% of the population - 1500 mg
sodium (IOM)
• Current intake ≈3600 mg/d
• ≈60% reduction required by food industry
• This will require legislation to ensure a level
playing field
• Start now with a voluntary policy whilst
legislation is enacted
29. 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 companies
opted for a regulatory approach as it gave
them a guarantee of a level playing field
• Salt targets for individual food groups
currently being set
30. 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 yet
Global 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
31. Salt - Summary
Every country in the world must now
1. Set up salt reduction plan
2. Implement the plan
This is the single most
cost-effective public health measure
It would be negligent for any
government not to take action now
www.worldactiononsalt.com
Hinweis der Redaktion
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&S and EAT. Who are reviewing their products
