Consensus Action on Salt and Health

Salt Awareness Week menu

House of Commons reception

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As part of Salt Awareness Week 2010, CASH held a lunchtime reception at the House of Commons. Over 100 people attended including MP's, Peers, Food Industry, NGO's and other health professionals. The Event was kindly sponsored by Mary Creagh MP and we were lucky enough to have Gillian Merron (Minister for Public Health), Tim Smith (FSA CEO) and Dr Ailsa Welch (National Osteoporosis Society) come along to speak.

Mary Creagh MP, Chair and Host
Mary Creagh opened the reception by welcoming everyone to the ‘healthiest reception to be held in the House of Commons’ this year and thanked everyone for their support.

Mary Creagh went on to speak about introducing the Childrens Food Bill in 2005, and said that raising awareness about unhealthy eating and helping this generation and the next make healthy choices is absolutely vital. She also said that she was delighted to be hosting, and chairing the event for CASH for the third time.

Mary Creagh continued by talking about the focus of this years Salt Awareness Week-  Salt and your health, and said that because of the hard work of organisations like Consensus Action on Salt and Health (CASH) most people are now aware that high salt causes high blood pressure and heart problems. She went on to say that we still have some work to do to take that message into certain hard to reach communities. Findings suggest people don’t know high salt diet leads to stomach cancer, osteoporosis, kidney stones and stroke. Mary said that she didn’t know the link with osteoporosis herself that this gap in public and political understanding makes this years week all the more crucial. We need to make real progress in communicating the less well known health dangers of salt.

Mary Creagh then concluded by introducing the speakers starting with Professor Graham MacGregor, Chairman of CASH and Professor of cardiovascular medicine for 20 years at St George’s Hospital, a world expert in health related salt questions. Mary also introduced the other speakers Gillian Merron, Minister of State for Public Health, Tim Smith Chief Executive of the Food Standards Agency and Ailsa Welch from the National Osteoporosis Society.

Professor Graham MacGregor, Chairman of Consensus Action on Salt and Health

Professor MacGregor began by thanking Mary and said how grateful he was for her hosting this event, and also thanked her for a great introduction. He also thanked the other speakers.

Professor MacGregor then went on to talk about having great support from so many other health charities – including British Heart Foundation, Blood Pressure Association, Osteoporosis Society, Kidney Research UK, Cancer Research UK, Asthma UK, The Stroke Association, National Obesity Forum, Menieres Society, Children’s Food Campaign, School Foods Trust and Netmums. Thanked all for being on board and supporting one of the most important public health programmes in UK. The UK is currently leading the world in the reduction of salt, and the levels have already fallen quite rapidly because of the reductions that have been made in all foods without people even being aware of it.

Professor MacGregor then extended his gratitude to the British Heart Foundation and food companies who provided financial support for the event including British Heart Foundation, Waitrose, Sainsbury’s, Marks & Spencer’s, Morrison’s, ASDA, The Co-operative, Lo-Salt, Heinz, PepsiCo and McCain. He highlighted that these are some of the leading companies in getting salt contents of their food right down, far more than other companies. Furthermore he gave special thanks to the Marcella Trust who have been the only people to provide money to CASH with particular thanks to Dawn Lawson, Kelly Lamb and Natasha Malbey who are trustees of the Marcella Trust and also to Katharine Jenner and Hannah Brinsden for organising the event.

Professor MacGregor then drew on Mary Creagh’s summary of the week, highlighting that the focus this year is the other deleterious effects of salt on health. He then said that we are all aware that salt is dangerous, 90% of adults in the UK know it is bad, 70% are aware that it is the major factor in raising blood pressure, 50% know that salt is related to heart disease and yet surprisingly only 20% know the link with stroke even though 60% of all strokes are due to high blood pressure. Interestingly there is very little awareness that osteoporosis, stomach cancer and kidney disease are all important problems that salt can cause or aggravate.

Professor MacGregor went on to say that salt is the most important control of calcium in the urine. Salt leaches the calcium out causing a negative calcium balance and therefore salt can have an important aggravating role. Salt is also an aggravator of stomach cancer as it is a deeply irritant substance which can encourage H.pylori infection. Salt is also an important accelerator in the rate of deterioration of kidney disease in people who already have it. Professor MacGregor then emphasised that the overwhelming evidence is for high blood pressure, which is the biggest cause of death worldwide through heart attacks and strokes, causing more deaths than smoking.

Professor MacGregor proceeded to say that everyone is and should be particularly proud this year as this should be the year of salt throughout the world. He said that CASH is working hard with the world action group and other countries around the world, with particular success in Canada, Australia and America. New York has recently announced that they will adopt same policy that we pioneered to get gradual reduction in salt added by the food industry and catering industry.

Professor MacGregor then concluded by thanking the food industry for cooperating, in terms of voluntary reductions, and although CASH would like them to work quicker and to a greater extent, he does want to congratulate the food industry as it has a huge public health benefit. He then urged the industry to continue with the reductions and if they do not, CASH will name and shame. For instance, a Dispatches programme in October highlighted Kellogg’s cereals as having high salt and as a result, they have now made a 30% reduction to the salt in their Cornflakes and Rice Krispies. When CASH started, Kellogg’s cornflakes were 10% more salty than seawater and now they contain 40% of the amount of salt in seawater meaning that they have come down by more than 60%. Although they still are the highest salt cereals in general across the market, at least they are doing something, although CASH would like them to continue with their reductions.

Gillian Merron MP, Minister of State for Public Health

Gillian Merron thanked Graham MacGregor for inviting her to speak and went on to say that she was delighted to join Mary Creagh whose zeal on salt and causes of salt is legendary and she is great campaigner on the effects of salt. So many of us have no idea of the effects of salt on our health. We know in rough terms, but the real message is what we are here to discuss today.

Gillian Merron then drew on the latest alcohol campaign which she helped to launch with the Stroke Association, British Heart Foundation and Cancer Research UK. She said that she did not realise that drinking too much alcohol is not just about liver disease, but heart disease, stroke and cancer, just as she didn’t know that salt was about more than just high blood pressure. She commented that if she did not know these links when launching campaigns, how can anyone else be expected to know?

Gillian Merron continued by stating that she believed that CASH has lived up to its name, and really has built a genuine consensus action around salt. This is very much demonstrated when she walked in to the room by the fantastic array of people with interest an in this topic.

Gillian Merron then stated that it is very straight forward, salt that we eat does affect our blood pressure and very simply we do need to reduce the amount that we eat. Gillian Merron went on to say that she believes that the reduction that has been achieved so far shows that the message is getting through, as the message can now be seen daily. There is a common parlance, whether it is newspapers taking on Jamie Oliver over the amount of salt in his recipes, or the supermarkets reducing the salt in their ready meals, it is now common culture and everyday chat – whether at check out or in the class room, we are talking about salt levels more and this is very encouraging and we have all had a role to play in this.

Gillian Merron when on to say that thanks to the efforts of everyone so far, we have trimmed just under 1g for our salt from average daily intake. This does not say much until you translate it. Just that 1g can prevent 6,000 premature deaths each year, and can save £1.5billion to the economy through days lost at work and to the NHS. This is something that everyone from the FSA to the industry can be very proud of.

As we are now taking the next steps, Gillian Merron said that it is worth reminding ourselves that the UK are the world leaders, and that other people are looking to the UK at what we are doing. She welcomed the latest FSA’s latest ad campaign about hidden salt levels and is thrilled with how attention it got and it is a great example of how we need to be more innovative to talk to people. .

Gillian Merron then concluded by saying we all expect more, I expect more, you expect more.  I know many want to see daily limits reduced even further. So, as we move into this year and throughout the year, the next series of voluntary targets for the industry kick in, so lets keep up the momentum, and let’s keep off the salt.

Tim Smith, Chief Executive, Food Standards Agency
Tim Smith began by thanking CASH for inviting him and said that he was delighted to be at the event to show FSA’s continual support for Salt Awareness Week. He went on to summarise the FSA’s work on salt, and explained that the FSA has now been working on salt reductions as part of its core activity for 6 years (since 2004) and in the Autumn launched the 4th phase of its salt awareness campaign involving TV and press advertising to highlight the slogan ‘Salt. Is your food full of it?’. The campaign highlighted foods which consumers are surprised to learn contributed a significant amount of salt to their diet, and importantly gave simple steps to choosing lower salt options to make a big difference to salt intake.

Tim Smith went on to say that the FSA is tracking awareness of salt in consumers along with the campaign messages. When the campaign started, 1 in 3 adults thought that they were making a special to get the salt in their food down – now 50% are making a special effort to reduce the amount of salt in our diets. Although the investment in advertising is modest it is making a difference to consumers awareness of the issues.

Tim Smith then acknowledged that it is the food industry itself who have a huge part to play through reformulation and helping to get the messages across. He then went on to summarise key industry updates. Most retailers (and all UK retailers which the FSA has dealings with) have made great progress in achieving the targets. ASDA and Sainsbury’s have met the targets across 80% of their products, and Waitrose has now achieved the 2010 targets in 100% of the products. The Coop and Marks & Spencers have also made considerable reductions and this message can be seen in store, and talking to their own customers. Manufacturers have also made considerable reductions. Allied bakery was on target for to achieve the targets at the end of last year, Kraft has taken 33% salt out of its cheese products and snacks, Heinz has taken a third out of its canned pasta and baked beans. Premier Foods is reformulating all of its Batchelors products to help achieve the 2010 targets. Just an example how a reduction can be achieved in small simple steps. Overall sodium has reduced by up to 70%. The FSA is often criticised for not going after the out of home market but said that McDonalds has made reductions of  14-75% depending on the product, and Brakes a major supplier to food service sector has met its targets across 70% of its products. Tim then directed people to the FSA website, which gives a full and coherent view of all achievements to date.

Tim Smith proceeded to say that while the industry has made a great achievement, it is because of CASH who has persuaded and encouraged them that the changes have actually happened. CASH has made a real effort to push home the message that this is such an important public health issue. They have kept the profile of this issue high, and have highlighted the need for real action.

Tim Smith then expressed delight at the UK being seen as the leaders around the world. The UK is active in the European Commission group on Nutrition and physical activity, developing a framework in salt reduction.  25 out of 27 member states have committed to take action against the framework. In January, New York City health department published voluntary salt reduction targets as part of their national salt reduction initiative involving 27 national health organisations and 26 states, cities and other bodies. New York acknowledged that their work is modelled on UK achievements which we should be proud of, and they have quoted the UK work in their successes to how reduction can work.

Tim Smith then closed by saying that CASH has really contributed to the global effort and the FSA thanks CASH, the food manufactures and all other interested parties for making the salt reduction really happen.

Dr Ailsa Welch, National Osteoporosis Society

Dr Welch began by thanking CASH for inviting her to speak, and said she would be representing the National Osteoporosis Societies views on salt and osteoporosis and will present some research on the links between salt intake and bone density.

Dr Welch explained that The National Osteoporosis Society exists to promote awareness, diagnosis and prevention of the treatment of osteoporosis. Osteoporosis is a condition which occurs with age and involved decreased density of bone, and increased fragility of bones which can lead to a predisposition to low trauma fractures. Dr Welch then used an analogy of bone being like a sponge, when you are young the bone has small holes and a obvious structure. As you age, the holes get bigger and the struts become smaller.

Dr Welch proceeded by saying that osteoporosis is going to become a great deal more important in the UK due to the rapidly aging population. Currently we have over 1/3 of the population over 50, and by 2020 it is predicted that there will be over 25million people over 50. Women are at a higher risk of loss of bone density because of loss of oestrogen hormone as they age. Hormone replacement therapy in women has been shown to prevent bone loss. Fractures are very prevalent in the over 50 age group, with 1 in 2 women, 1 in 5 men experiencing a fracture over the age of 50. This shows that it is very common occurrence, and not uncommon in men either.

Dr Welch continued by saying that as well as health effects there are also considerable cost effects of osteoporosis to the government and to the National Health Service. The current estimates are that the cost is 2.3million pounds per year for care of fractures and falls which has huge consequences for health and social care. Of the people who have a hip fracture, half are still unable to walk within a year, meaning that they need continuous care.

Dr Welch then went on to answer the question ‘How does salt fit it in with this’? She explained that calcium maintains bone density and is needed at all ages. The adult recommendation is 700mg/day. Calcium is important for many functions and is tightly controlled so the body aims to maintain calcium balance. Nearly 100% of calcium is in the bones. Salt can create excretion of calcium in urine meaning that if you don’t absorb enough from the diet to balance the loss then this can induce a process called bone reabsorption which means that calcium comes from the bones into the circulation. These short term effects of bone reabsorption can lead to longer more chronic effects in terms of bone health.

Dr Welch then went on to discuss some of the evidence surrounding salt and calcium balance. She explained that there is growing evidence that an increased salt intake increases calcium in the urine. Dr Welch then drew everyones attention to some recent research headed by Sue Fairweather of the Tait group in Norwich published in the bone and mineral research journal, where women were placed on different diets of calcium and salt and their calcium balance measured. It was found that on a high salt intake women were not in balance even with a high calcium intake. The levels used in each of the diets were based on the higher and lower ends of the UK diet.

Dr Welch then went on to say that although there is increased excretion of calcium though consuming more salt, because calcium is tightly controlled, the most direct evidence looks at links between bone density and fractures. She then highlighted some research by the Richard Princes group in Australia which looked at salt excretion in the urine and followed people for two years before measuring the change in bone density. A small effect was found, with a greater effect found in those with higher salt excretion. This adds to the growing evidence that increased salt increases calcium in the urine.

Dr Welch then presented some of her own research which looked at the difference in bone quality based on heel bone ultrasound attenuation, in more than 7,000 women aged 45 – 75 in the UK. It looked at urine samples and calcium in the diet. Those with low salt urinary excretion and a high calcium diet had the greatest bone quality, with a 7% difference compared to high salt urinary excretion and a low calcium diet.  This difference is the equivalent to the effects of taking hormone replacement therapy, and therefore is considered quite large. Dr Welch then said that the best evidence for a link with salt would look at the relationship between salt intake and calcium intake and risk of fracture but there is not yet evidence for this.

Dr Welch concluded by explaining that the current view of the National Osteoporosis Society is that reducing salt intake is beneficial for overall health with benefits to the heart and to blood pressure, but also to bone health. High intake salt increases calcium loss from the urine. Blood pressure may also be a factor responsible for accelerating calcium loss from the body. As calcium is vital for bones, anything which causes it to be lost from the body can have an impact on bone strength.

Q & A Session

Question 1 
Andrew Dougal, Northern Ireland Chest Heart and Stroke Association

What is being done to target people in deprived areas where the huge burden of heart disease is most rampant. This is a total population approach which is welcome and very good, but what can we do in a targeted way to help those in deprived areas to get them to reduce the salt in their diet?

Answer 1 
Professor Graham MacGregor, Chairman of Consensus Action on Salt and Health

Agreed with Andrew Dougal that deprived people are the most likely to get cardiovascular disease, heart attacks and strokes and there is a need to target these people. He went on to say that CASH has always tried to get the biggest reductions in the cheapest products such as sausages and bread. The supermarket’s breads have had the greater reduction in general compared to the breads from Hovis and Warburtons which have had less reductions. It is important to focus on this type of product as people from deprived areas can’t afford to buy a healthy diet, and will instead buy the cheapest so need to make sure that it is these products which have the biggest reductions in salt. Professor MacGregor then went on to say that it is difficult to educate these people as they have no choice but to buy the cheapest food, while affluent people have the choice to buy more fruit and vegetables which are difficult to subsidise. We need to ensure that we target public health policies at those at most risk, rather than the more affluent who are already on more healthier diets.

Question 2 
Alexandra Kemp,
What is the role of free school meals in deprived area in this agenda?

Answer 2 
Mary Creagh MP, House of Commons

Explained that there have been a number of free school meal pilots around the country. The original pilot in Hull has now ended, but it did show that the benefits of giving school meals to everyone was that it increases take up and also gets children from poorer backgrounds to think that healthy eating is the normal thing to be doing. Children are very quick to stereotype about themselves and other people - the ballet girl and the burger boy are the main ones categorised in the research. Mary thinks that free school meals are particularly important to take away this stigma from school dinners, and also with the new minimum standards introduced we now know they will not exceed the recommendations for salt intake for their age group. It is important to remember that 5 years ago the levels of knowledge and awareness, and particularly around childrens around this was very very low, thanks to work of school food trust and manufacturers we have come an enormous distance.

Question 3 
Sue Masham, House of Lords

Lo-Salt: is it any good, it tastes awful!

Answer 3 
Tim Smith, Chief Executive, Food Standards Agency

Gave a brief overview of all answers from the FSA perspective.

Lo-Salt - The answer is important for agency – what the FSA does is what works for consumers in their daily lives, so if product doesn’t taste good as a consequence of reformulation it won’t work and that product won’t sell.

Free school meals – as a recipient he feels that they encourage the correct diet, but only if the choices are provided in the school, and the schools food trust relies on the FSA to get nutritional advice. In terms of school meals,  getting the uptake up is what is critical and this is what the work needs to involve.

In response to the question about people in deprived areas, an enormous amount of work is needed to find out what works for deprived people. This country has a high level of good manufactures and retailers, with access to the consumers in a way that other countries can only dream of. 

Answer 3
Graham MacGregor, Chairman of Consensus Action on Salt and Health

Salt is sodium chloride, Lo Salt is potassium chloride. It is ok for the majority of population in small amount, although some get a very bitter after taste. The most common example of potassium salt is Lo Salt which contains 70% potassium chloride, and 30% sodium chloride, which does have a blood pressure lowering effect. From a health benefits point of view, Lo Salt is better. What he says to high blood pressure patients is that if you have to add a white chemical, which we recommend you don’t, then use Lo Salt and not salt. If you use very little of it is ok, if you use a lot of it isn’t. A study from Northern Ireland on ready meals, showed that by using a mineral salt (such as Lo Salt) you are able to get the salt down further, and consumers even preferred the meals made in this way.

Grahams own view is that we should just reduce salt and get used to the taste of low salt because our salt taste receptors will adjust and have a higher sensitivity towards salt so that a lower concentration has a very salty taste. And this is why this programme works. There have been so many reductions and no one has even noticed. If you ask the average consumer whether they know that salt has been reduced by 30% they will say no. He would like to see that where salt reduction may be a problem for the manufactures where, that they instead use potassium salts. He finished by saying that he was disappointed that the FSA and the industry is opposed to using potassium, and believes that worldwide it will become much more common. Stated that people are opposed to the use because they do not want to add any chemicals to their food because they think that the public won’t buy them, and yet they are already doing so in the form of salt.

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