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.