Relaxing Salt Targets Linked to Extra Cases of CVD and Cancer

Peter Russell

July 19, 2019

An agreement to relax UK regulation of salt content in food was linked with an estimated 9900 additional cases of cardiovascular disease, and 1500 additional cases of gastric cancer, research found.

For 7 years leading up to 2010, the UK had a scheme led by the Food Standards Agency (FSA) to reduce salt intake. The strategy included the use of agreements with the food industry to reformulate processed foods, increase public awareness, and introduce food labelling.

The FSA monitored salt content and agreed on targets for salt reduction with industry.

It was backed up by the threat of mandatory imposition if industry failed to comply.

In 2010, responsibility for nutrition transferred from the FSA to the Department of Health and Social Care (DHSC), then called the Department of Health. In 2011, salt targets were replaced in England by the Public Health Responsibility Deal, which ran until 2017. Under the scheme, the food industry was allowed to set its own targets and report progress to the DHSC.

Analysing the Health Impacts of the Responsibility Deal

New research, published in the Journal of Epidemiology & Community Health , estimated the impact of the public-private partnership deal on trends in population-level salt intake and associated changes in cardiovascular disease (CVD), gastric cancer (GCa), and mortality, as well as an estimate of the economic costs in England from 2011 to 2025.

The study found that since the regulations on industry were relaxed in 2011, the national decline in salt intake had stalled.

In 2000 to 2001, mean salt intake was 10.5 grams per day in men and 8.0 grams per day in women.

Between 2003 and 2010, salt intake was falling annually by 0.2g a day for men, and by 0.12g a day for women.

However, between 2011 and 2014, after the Responsibility Deal was introduced, annual declines had slowed to 0.11g per day for men, and 0.07g per day for women, the study found.

Data was drawn from the National Diet and Nutrition Survey (2000, 2001) and national sodium intake surveys taken from the Health Survey for England for the years 2006, 2008, 2011, and 2014.

Mandatory Targets 'More Effective Than Self-regulation'

Dr Anthony Laverty from Imperial's School of Public Health, who led the study, said the Responsibility Deal lacked robust and independent target setting, monitoring, and enforcement. "Evidence from around the world is now showing that mandatory approaches are much more effective than self-regulation by industry in reducing the amount of salt and sugar in our diet."

As well as the cost to public health, the researchers estimated that relaxing the food industry regulations cost the economy around £160 million from 2011 to 2018, taking into account additional healthcare costs, deaths, and workplace absences.

Using computer modelling, the researchers estimated future cases of cardiovascular disease and stomach cancer if the average reduction in salt intake continued at the current rate. They predicted an estimated additional 26,000 cases of cardiovascular disease, and 3800 cases of stomach cancer between 2019 and 2025.

Health impacts were higher in deprived areas, leading to a widening of health inequalities, the study found.

The cost to the economy during this period could be an additional £970 million, according to the researchers.

Prof Martin O'Flaherty from the University of Liverpool, who co-authored the study, said: "The FSA approach was one of the most robust strategies internationally. Our research shows that we now need an equally robust mandatory programme to accelerate salt intake reduction. This will require clear targets and penalties to ensure the food industry reduce salt content in foods.

"Softer, voluntary measures could generate additional heart attacks, strokes, and cancer cases."

The study authors acknowledged some limitations with their research including a lack of repeated measures of salt intake in the same individuals, and comparatively small sample sizes.

However, they concluded that "without independent targets and monitoring, PPPs [public-private partnerships] are unlikely to deliver the improvements in population health claimed by their proponents".

Reaction to the Study

Graham MacGregor, professor of cardiovascular medicine at Queen Mary University of London, told the Science Media Centre: "It is a scandal that the UK currently has no active salt reduction strategy, with the last set of salt reduction targets having expired at the end of 2017.

"Salt reduction is a shared responsibility and while the food industry do have their part to play in helping consumers eat less salt, this research clearly demonstrates the need for a robustly monitored programme to ensure that progress towards published targets is maintained and, where there is a lack of progress, it is addressed in real time."

Tracy Parker, senior dietitian at the British Heart Foundation, said there was "a wealth of evidence that links a high salt consumption to raised blood pressure, a risk factor for coronary heart disease and stroke".

However, she added: "These findings are interesting, but it is only an observational modelling study that looks at data over time.  It does not give us an accurate reflection of why there has been a recent slower decline in salt intake."

Tom Sanders, professor emeritus of nutrition and dietetics at King's College London, commented: "One reason why salt reduction has hit the buffers is that many consumers find unsalted food unpalatable, and salt also has a role in food preservation. 

"Further reductions in the level of salt in processed food may be better achieved by encouraging the partial replacement with potassium chloride for salt rather than heavy handed legislation."

'We Continue to Drive Further Progress': Government

Commenting on the research, a spokesperson for the DHSC said: "We are committed to people living longer, healthier lives, and our progress on salt reduction is world leading.

"Voluntary action has seen an 11% reduction over the last decade and we continue to work with industry to drive further progress."

Public Health England (PHE) acknowledged that more work needed to be done on reducing dietary salt. Dr Alison Tedstone, PHE's chief nutritionist, said: "PHE's review last December shows a mixed bag across industry with just over half of all average salt reduction targets met, with retailers making more progress than manufacturers. It is clear that with the right leadership from industry, further salt reduction in foods is still possible."

Tim Rycroft, chief operating officer for the Food and Drink Federation (FDF), said: "FDF members have led the way in voluntarily reducing salt in food. Compared with 4 years ago, FDF member products contribute 14% less salt to the average shopping basket, continuing to build on 2 decades of steady reformulation work following successive voluntary targets.

"Thanks to the huge amount of work that has already been completed over a long period of time, it is no surprise that the rate of change will slow down. Most ingredients in food perform a wide range of functions, and go well beyond adding flavour, such as providing texture or shelf-life. This means taking anything out of food (through reformulation), be it salt, sugar or calories, is not straightforward.

"We recognise there is more to be done and manufacturers remain committed to the government’s various reformulation programmes."

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study, Laverty A, et al, Journal of Epidemiology & Community Health. Paper .

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