Salt - intake, reduction and
regulation in South Africa
Melvyn Freeman
Cluster Manager Non-communicable
Diseases
• The South African diet is high in salt,
with an average intake of 7.8 grams per
day in black people, 8.5 grams per day
in those of mixed race, and 9.8 grams
per day in whites.
• Various international agencies including
the World Health Organization
recommend maximum salt intakes of
between 4 and 6 grams per day.
•
Why the fuss?
• Excessive salt leads to increased risk of
stomach cancer, kidney failure,
dehydration, high blood pressure and
hypertension, which in turn can
contribute to heart disease and strokes.
• According to the latest Stats SA
mortality statistics, diseases of the
circulatory system are the second
highest cause of all deaths in South
Africa.
• High blood pressure is responsible for
more than 40% of Ischemic Heart
Disease, almost 50% of stroke, and
more than 70% of hypertensive heart
disease. An estimated 6.3 million
people in SA suffer from hypertension.
•
• High dietary salt intake is estimated to
cause about a third of all hypertension.
• Most salt intake is in processed food
rather than added to it.
• Our target is to get to 5 grams of
sodium intake per day. ..
Hypertension (bp>140/80 or meds)
Men South Africa
Hypertension (bp>140/80 or meds)
Women South Africa
100
100
78
80
70
42 39
40
4
50
34
40
20
11 10
0
38
52
7
80
60
40
20
2931
3841
45
51
50
43
4244
1998 SADHS
7072
7275
7272
35-44
45-54
55-64
72
60
5658
60
40
38
1998 SADHS
30
2008 NIDS
1113
2008 NIDS
20
0
0
15-24
25-34
35-44
45-54
Age group
55-64
65+
15-24
25-34
65+
Age group
44
24 24
2008 NIDS
20 22
20
1998 SADHS
60
Overweight and obesity (BMI>25)
Women South Africa
100
80
Percentage
52
Overweight and obesity (BMI>25)
Men South Africa
100
Percentage
60
71
63
60
60
Percentage
Percentage
80
1998 SADHS
2008 NIDS
12 15
0
15-24 25-34 35-44 45-54 55-64 65+
15-24 25-34 35-44 45-54 55-64 65+
Age group
Age group
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.
Atheroma in carotid artery
Plaque
Ulcerated
Plaque
Fissured Plaque
with Thrombosis
What puts up population BP?
• Salt intake
• Lack of Fruit and vegetables
• Weight
• Lack of Exercise
• (Alcohol excess)
Randomised Double-Blind Crossover Study (N=20)
Salt Intake (g/day)
12
6
3
165
160
Systolic BP
(mmHg)
155
150
145
P<0.001 by repeated measures ANOVA.
100
Diastolic BP
(mmHg)
95
90
P<0.001 by repeated measures ANOVA.
200
Urinary Sodium
(mmol/24h)
150
100
50
0
MacGregor et al. Lancet 1989;2:1244-7.
Meta-analysis of Modest Salt Reduction Trials of one month or Longer
Hypertensive
Normotensive
0
Fall in
Systolic BP
-2
(mmHg)
-4
***
-6
***
150
Urinary
Sodium
100
(mmol/24h)
50
Usual salt intake
0
***
P<0.001 reduced salt vs. usual salt intake.
Reduced salt intake
J Hum Hypertens. 2002;16:761-770
Dose Response: Meta-analysis (1 month or longer)
4
2
0
-2
Change in
Systolic BP
(mmHg)
Normotensives
b=0.04, P<0.001
-4
-6
-8
Hypertensives
b=0.07, P<0.001
-10
-12
-30
-50
-70
-90
-110
-130
Change in Urinary Sodium (mmol/24h)
\A6
g/day reduction in salt intake predicts a fall in SBP of:
 7 mmHg in Hypertensives (p<0.001)
 4 mmHg in Normotensives (p<0.01)
 Avg. 5 mmHg
J Human Hypertens 2002;16:761
 Salt intake 5-6g/day
 Stroke 24%
 CHD 18%
He & MacGregor. Hypertension 2003;42:1093-99
UK
35,000 (approx) Stroke &
heart attack deaths
prevented / year
Worldwide 2.5 million (approx) deaths
prevented / year
Outcome trial
0.20
TOHP I
0.16
Control
Cumulative 0.12
Incidence
of CVD
0.08
Salt reduction
0.04
0
0.10
Cumulative
Incidence
of CVD
TOHP II
0.08
Control
0.06
Salt reduction
0.04
0.02
0
2
4
6
8
10
Follow- up (years)
12
14
16
Cook et al. BMJ 2007;334:885
 25% Salt intake (↓2.5 g/d)   25% CVD events
Finland
Salt intake
(g/day)
Diastolic BP
(mmHg)
Stroke mortality
(1/100000)
Men
Men
Women
Women
Year
Year
Year
Karppanen & Mervaala. Prog Cardiovasc Dis 2006;49:59-75.
Hidden
Salt
in
food
e.g. processed, fast, takeaway, restaurant food
Food industry slowly reduce
- No rejection by public
Fantastic for Public Health
Very little
cost
↓ BP
No need to
change diet
Perceived Barriers
1. Taste
2. Food technology
3. Safety
4. Commercial
• In an 8 week randomised controlled
study in the Western Cape it was found
that by replacing commonly consumed
foods with reduced salt products
significantly reduced blood pressure.
• The number of deaths that can be averted by
reducing salt content just in bread (though not
eliminating salt) in South Africa has been
estimated at around 6 500 per annum.
Mortality attributable to hypertension could be
reduced by 16% in women and 13% in men.
Total disability adjusted life years averted
was estimated at 56,000 per year.
Why regulate?
• It is the obligation of the DOH to
improve health. Reducing salt content
will save many lives and lead to a
healthier population so salt intake must
be reduced.
• Self regulation is a possibility but this
results in uneven playing fields – even
most of the food industry supports
regulations rather than self-regulation.
What should be regulated?
• All products with salt?
• One product known to impact
population health the most ie bread?
• The saltiest products?
• A range of products that have been
found to be primarily responsible for the
levels of salt intake within the
population?
So which products are we
proposing to regulate and to
what levels?
• The Minister of Health intends, under
section 15 (1) of the Foodstuffs,
Cosmetics and Disinfectants Act, 1972
(Act 54 of 1972), to make regulations
set out in the Schedule hereto.
• Foodstuff category
• Maximum Total Sodium per 100 g
foodstuff
• Date on which the total Sodium
reduction becomes effective
• 30 June 2014
• 30 June 2017
Products
• Bread without “high salt” additions such
as cheese, olives, processed meat,
sundried tomatoes and other
ingredients
• Bread with “high salt” additions such as
cheese, olives, processed meat,
sundried tomatoes and other
ingredients
• All breakfast cereals, including hot oat
and other hot and instant porridges
• All margarines and fat spreads
• Table butter
• Ready-to-eat savoury snacks
• All flavoured potato crisps
• Processed meats (as defined
• Raw-processed meat sausages (all
types)
• Dry soup and gravy powders, dry
powder flavour mixes intended for, and
sold with instant noodles
Definitions
• “bread” means white bread, brown bread, wholewheat bread and speciality bread as defined by the
Regulations Relating to the Grading, Packing and
Marking of Wheat Products intended for sale in the
Republic of South Africa, R186 of 22 February 2008
under the Agricultural Products Standards Act 1990,
(Act No 119 of 1990) and any future revision thereof,
including buns and rolls, pre-packed, part-baked or
baked, excluding rye bread where rye is the only or
major cereal present;
• “processed meats” for the purpose of
these Regulations means all reformed
or emulsion type processed meat
products in a sausage, meat loaf and
meat spread form, that have been
comminuted, coated or un-coated,
cured or uncured, or heat treated or no
or partial heat treated;
•
• "raw-processed meat sausages" means all types
of raw-processed meat sausages from all species of
meat animals and birds intended for human
consumption in South Africa, cured or uncured, or a
combination thereof, that has not undergone any heat
treatment and where any added ingredient and/or
additive and added water, including brine, is retained
in or on the product as sold, but exclude processed
meats in sausage form as defined by these
Regulations;
• “Ready-to-eat savoury snacks”
means all savoury, flavoured
extruded/expanded or puffed snacks
made from potato, corn, rice or other
cereals, savoury, flavoured snacks
made from pellets, savoury, flavoured
popcorn, filled and unfilled savoury
biscuits, excluding potato crisps.
• “Table butter” means butter not used
or present as an ingredient in other
composite foodstuffs;
•
• “total Sodium” means Sodium from
Sodium Chloride (table salt) and any
other ingredient or additive sources.
How will we monitor?
• Methodology to determine total Sodium
content directly through chemical
analysis by using a suitable
potentiometric method or elemental
analysis with AA (Flame atomic
absorption spectroscopy) or ICP
(Inductively Coupled Plasma) shall be
used.