The Chief Medical Officer’s annual report highlighted salt, saturated fat and sugar as key areas of concern in terms of achieveing better health in England by 2040. Of the 15 recommendations made in the report, two specifically referenced salt:
- Recommendation 6 I recommend that HM Government review the use of fiscal disincentives in relation to foods that are high in sugar and salt and also incentives to increase fruit and vegetable consumption
- Recommendation 7 I recommend that in 2019, HM Government through Public Heath England need to set more ambitious targets for salt reduction in food. This should apply equally to the out-of-home sector, which has lagged behind. If these targets are not met then they should be mandated and a range of other interventions considered, including mandating front on pack labelling
In December, Public Health England released their analysis of industry progress towards achieving the 2017 salt targets. Targets were set across 76 categories of food in 2014, covering the main contributors of salt to the UK diet, providing 54% of dietary salt. Both average and maximum salt targets were set across the majority of categoires. Additionally, 24 maximum salt per serve targets were set across meals available in the out of home sector, including childrens meals, pies and pasta meals. Only 52% of average targets were met by retailers and manufacturers, with retailers meeting 73% and manufacturers just 37%. Meat products didn’t meet any average targets and 43% of meat products were higher in salt than their maximum targets. 29% of dishes served in the out of home sector were higher in salt than their targets.
In November 2018, the Department of Health and Social Care (DHSC) released their Prevention is better than cure vision document, outlining strategies for disease prevention in recognition of the fact that the UK spends £97 billion of public money on treating disease, but only £8 billion preventing it. The vision document promised salt reduction plans in a green paper, due to be released by Easter 2019. The DHSC estimated that if the UK’s average salt consumption could be reduced from its current level of 8g to the recommended maximum of 6g per day, over 8,000 premature deaths could be prevented each year, which would save the NHS more than £570 million annually.
Action on Salt, World Action on Salt and Health and Blood Pressure UK issued a joint position paper on the use of potassium-based sodium replacers to lower dietary salt intake. This follows the joint report from the Scientific Advisory Committee on Nutrition and the Committee on Toxicity.
In May, Action on Salt and Action on Sugar launched a combined updated seven-point evidence-based plan to prevent obesity, type 2 diabetes, raised blood pressure, cardiovascular disease and cancer in the UK – with an urgent call for the Prime Minister to include ALL crucial recommendations in Chapter Two of her long-awaited obesity strategy.
Action on Salt published a paper in the journal Public Health Nutrition, looking at the salt and sugar content in UK breakfast cereals between 2004 and 2015. The survey found that the salt content of breakfast cereals has decreased by approximately 50% over the past 10 years owing to the successful salt reduction programme – particularly the target-based approach to gradually reduce salt added to food.
Following on from the dissolved Responsibility Deal, which ceased to function after the 2015 General Election, Public Health England re-published the 2017 Salt Targets as part of their 'Sugar reduction and wider reformulation programme', one of the main commitments in Childhood obesity: a plan for action.
Action on Salt Chairman Professor Graham MacGregor and member Dr Feng He have been awarded £6.6m by the National Institute for Health Research (NIHR) to establish a new Global Health Research Unit in China - Action on Salt China. This award comes from the NIHR’s Global Challenges Research Funding.
A Joint report from the Scientific Advisory Committee on Nutrition (SACN) and the Committee on Toxicity (COT) found that the potential benefits of using potassium-based sodium replacers outweighed any perceived risks, and would have a large impact at the population level. They recommended that the government should encourage the food industry to consider the use of sodium replacers to reduce the sodium content of food.
It was announced that UK population average salt intakes are now at 8g/day. Adults have cut their average salt consumption by 0.9 grams per day in the decade from 2005 to 2014 according to new data from Public Health England’s National Diet and Nutrition Survey. Changes in methodology for the analysis of sodium have now altered the reported average UK salt intakes over the years, with figures now 'corrected' to 8.8g/day in 2005/06 and 8.5g in 2011. Therefore, it is now reported that salt intakes have fallen in the UK by 0.9g/day (11%).
Action on Salt member Dr Feng He and colleagues carried out an intervention study in China and successfully reduced salt intake through educating children who then instruct their family to reduce salt. Over one school term (3.5 months), salt intake was reduced by a quarter in both children, and parents and grandparents with a significant fall in systolic blood pressure in adults. A paper related to the study was published in the BMJ.
Following a decline in pressure from government on the food industry, an article by Professor MacGregor and colleagues was published in The BMJ calling for an independent agency to improve nutrition, which the Responsibility Deal has failed to do.
A study by Yuan Ma, Feng He and Graham MacGregor, published in Hypertension, has shown high salt intake can potentially increase risk of obesity in both adults and children. A 1 g/day increase in salt intake is associated with more than 25% increase in risk of obesity (both children and adults), independent of energy intake or sugar-sweetened beverage consumption.
The Department of Health set new salt limits beyond 2012 for the food industry to achieve. These targets cover 76 categories of food and are on average 10% lower than the 2012 targets. A new set of targets for the out of home industry were also published - Out of Home Maximum per Serving Salt Targets - in an attempt to get the out of home sector on board, and develop a level playing field.
Action on Salt published a new paper in the BMJ Open, looking at salt reduction in England and its relationship to blood pressure, stroke and ischaemic heart disease mortality. The paper concluded that the reduction in salt intake is likely to be an important contributor to the falls in blood pressure from 2003 to 2011 in England.
The Department of Health agree to review all of the 2012 salt reduction targets, as well as the development of a new target for meat extracts.
The World Health Organisation issue new guidance on dietary salt and potassium, stating that adults should consume less than 2,000mg sodium – or 5g of salt – per day and at least 3,510mg of potassium per day.
The Department of Health announce a new Salt Strategy to help cut salt consumption by a quarter. The government pledge to; revise the 2012 salt targets by the end of the year, set new maximum targets for the most popular dishes in an attempt to push the catering sector to do more, and increase sign up through the Responsibility Deal.
Action on Salt published a paper in the BMJ Open, looking at the salt content in UK bread between 2001 and 2011. The survey found that the salt content of packaged bread in the UK has reduced over time. This demonstrates that a well-managed voluntary programme of salt content targets can successfully lead to a gradual reduction in the salt content of food.
It was announced that UK population average salt intakes have fallen further from 8.6g/day to 8.1g/day. This is now the lowest salt intake of any developed country in the world. Studies suggest that this reduction in average daily salt intake, through the reduction it has on blood pressure, will prevent approximately 20,000 strokes, heart attacks and heart failure, 8,500 of which are fatal, in the UK every year. The figures were based on 24-hour Urinary Sodium analysis of a representative sample of the UK population.
The Department of Health published a new salt pledge targeted to caterers, to encourage caterers and their suppliers to play a greater role in salt reduction, and create a level playing field in the food industry. Three salt catering pledges were announced, which focus on training and kitchen practice, reformulation and procurement.
The American Heart Association reaffirmed its 2011 sodium reduction advice to limit consumption to less than 1500mg – or 3.75g of salt – per day. This was a rebuttal to some misleading papers published in 2011-12.
The Food Standards Agency nutrition team transferred to the Department of Health. Andrew Lansley commits to continuing the salt reduction programme through the 'Public Health Responsibility Deal' which outlines the key health commitments made by the food industry. The salt commitments are based on the previously set 2012 targets and involve a further 15% (1g) reduction by the food industry. To date more than 40 companies have pledged to reduce the salt content of their food.
The UN Summit on Non-communicable Diseases was held in New York. Salt reduction listed as one of the most important and cost effective ways to reduce blood pressure and CVD around the world.
A paper was published which projected the cost benefits of dietary salt reduction on future cardiovascular disease. The paper by Bibbins-Domingo et al and published in the New England Journal of Medicine makes for a further compelling case for salt reduction throughout the world. The paper emphasises the enormous public health benefits, and medical cost reductions, of salt reduction on cardiovascular disease.
The WHO and FSA held a meeting with experts from 33 countries to discuss worldwide salt reduction strategies. The meeting was also attended by key NGO's and food industry. Worldwide salt reduction is considered as important for public health as smoking cessation.
The Food Standards Agency published Healthy Catering Commitment to guide salt reduction in catering businesses. This represented a shift in focus to the out of home sector which had previously been put aside.
The National Institute for Health and Care Excellence published a report titled 'Prevention of Cardiovascular Disease ' which presented salt as the number one recommendation for CVD prevention. The report recommended that salt reduction be accelerated with the aim of achieving an average intake of 6g/day in 2015 and 3g/day in 2025. It also recommended that more emphasis be put on the recommendations for children under the age of 11 to ensure that children do not exceed their age specific recommendations. The food industry needs to continue offering lower salt foods and more low salt options need to be available with out a price increase. The report also provided a financial model that predicted that the salt reduction programme so far has made £1.5billion in savings for the NHS.
Results from a meta-analysis of prospective studies on salt intake, stroke and cardiovascular disease was published in the British Medical Journal. The analysis, by Professor Strazzullo and Professor Cappuccio, showed that a difference of 5 g a day in habitual salt intake is associated with a 23% difference in the rate of stroke and a 17% difference in the rate of total cardiovascular disease. Based on these results, reducing daily salt intake by 5 g at the population level could prevent 1.25 million deaths from stroke and almost 3 million deaths from cardiovascular disease each year.
It was announced that salt intakes had fallen to 8.6g per day. This 10% reduction is predicted to save 6,000 lives every year and represents a massive 19,700 tons of salt that have been removed from our food. The figures were based on 24-hour Urinary Sodium analysis of a representative sample of the UK population.
It became clear that the 2010 targets would not go far enough to reducing salt intake to 6g/day so 2012 voluntary salt reduction targets were set by the FSA. These targets covered 80 categories of food and were more challenging than the 2010 targets.
The Food Standards Agency set voluntary salt reduction targets for the food industry, covering 85 categories of food and due to be met by 2010. These were set with the intention of getting the population average intake of salt down to 6g/day based on Action on Salt’s model that the food industry would reduce the salt content of food by 40% and consumers would reduce a further 40% themselves. These targets failed to take into account food eaten out of the home and imported food.
World Action on Salt and Health (WASH) was set up to translate the success of the UK salt reduction programme to the rest of the world. WASH has expert members specialising in public health, cardiovascular disease, blood pressure and kidney health from around the world.
SACN published a report on salt and health which concluded that the evidence for a direct association between salt intake and blood pressure is much stronger than it was when the Committee on Medical Aspects of Food and Nutrition Policy (COMA) reports were written in 1994. The report recommended that salt intake be reduced to less than 6g/day for adults and reported that no evidence was found to suggest that reducing salt intake to this level would have any detrimental effect on health. The report also provided a breakdown in maximum recommendations for children under the age of 11. The report highlighted that while it is important for individuals to make changes to their personal habits it is also important for the food industry and catering industry to make reductions as well.
A paper was published by Professor Graham MacGregor and Dr Feng He indicating that salt intake should be reduced to 3g/dayto achieve the greatest possible benefits to health. MacGregor and He predicted that reducing salt from 12g/day to 3g/day would prevent approximately a third of all strokes and a quarter of ischaemic heart disease cases – equivalent to 20,500 deaths from stroke and 31,400 deaths from ischaemic heart disease every year in the UK alone.
The Food Standards Agency committed to a nationwide salt reduction initiative to reduce the UK salt intake to 6g/day. The initiative has since included famous campaigns such as 'Sid the slug', 'Check the label' and 'Is your food full of it?'.
WHO publish a report ‘preventing risks and promoting a healthy lifestyle’ which emphasised the global burden of high blood pressure and that it alone is responsible for 50% of cases of cardiovascular disease. The report also went on to discuss the high concentrations of salt found in many household foods such as bread, breakfast cereal, sausages and soup. As a result, it was established that the salt intake in industrialised counties is very high, with more than 75% of salt coming from processed foods.
In the 2001 'Chief Medical Officer Annual report', the CMO (Liam Donaldson) gave his support to achieving a national salt target of no more than 6g/day. He said "A major initiative by the food industry to reduce the salt content of processed and catered foods could help save lives in the long term. Immediate moves to provide clear information to consumers on salt and the sodium content of food products would bring major benefits". He also highlighted the significant evidence available in support of salt reduction as an important way to reduce blood pressure.
Action on Salt was set up by Professor Graham MacGregor as a response to the refusal of the Chief Medical Officer (CMO) to endorse the COMA recommendations to reduce salt intake.
A COMA report titled Nutritional Aspects of Cardiovascular Disease [PDF 20KB] was published which looked at the causal relationship between salt intake and both the level of blood pressure and the rise in blood pressure with age. It recommended that salt intake should be reduced gradually from 9g/day to 6g/day and that food manufacturers, caterers and individuals should explore and grasp the opportunity for reducing salt content of food and meals. At the time the Chief Medical Officer accepted all recommendations made in the report except for the salt recommendations. It is not known why this is, but it is thought to be due to pressure from the food industry.
The Committee on Medical Aspects of Food and Nutrition Policy (COMA) published a report on ‘Dietary Reference values for food, energy and nutrients for the United Kingdom’, which set Reference Nutrient Intakes for salt and well as other nutrients based on a risk-benefit analysis. The RNIs are considered suitable for 97% of the population. The RNI for sodium was set at 1600mg, which equates to 4g of salt. The report considered that “current sodium intakes are needlessly high and we caution against any trend towards increased intakes".