1、Global Salt Initiatives From Evidence to Worldwide Implementation,Graham A MacGregor,,Ezzati et al. Lancet 2002:360:1347-60.,Underweight,Unsafe sex,High cholesterol,Tobacco,Raised Blood Pressure,0,1,2,3,4,5,6,7,Millions of Deaths,7 million,Developing region,Developed region,Raised BP is responsible
2、for 62% of all Strokes & 49% of all Heart Disease,Major Underlying Factors Causing Death - Worldwide,Systolic Blood Pressure (mmHg),Heart Deaths,16,8,4,2,1,120,125,135,148,168,Risk,120,125,135,148,168,2,4,8,16,32,Stroke Deaths,The risk starts at systolic 115 mmHg (83% adults),Risk,MacMahon et al. La
3、ncet 1990;335:765-74,Systolic BP and Risk of Death,Plaque,Ulcerated Plaque,Fissured Plaque with Thrombosis,Atheroma in carotid artery,What puts up population BP?,Salt intake Lack of fruit and vegetables Weight Lack of exercise (Alcohol excess),He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.
4、2008.144.,Up to 5000 yrs ago 0.1 g/d, now 10 to 12 g/d,Why?,Preserves food,Cleans up bad food,Refrigeration Better chemicals,Now no need,But eating 10 to 12 g/d - courtesy of the food industry,80% of salt hidden in food,(a),(b),Salt, diet & health. 1998, Camb Uni Press,Salt,Evidence,Epidemiology Ove
5、r 50 population studies and Intersalt Migration e.g. Kenya Intervention Portuguese villages. New born babies Genetic All defects impair ability of the kidney to excrete Na Mechanisms Plasma Na, corrected volume expansion Animal BP caused or aggravated by salt (e.g. chimpanzees) Treatment Trials, Met
6、a-analysis. Dose response Mortality studies Finland (24h UNa) Outcome trials TOHP, Taiwan (mineral salt: high K, low Na),He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.,Hypertensive,Normotensive,Fall in Systolic BP (mmHg),Usual salt intake,Reduced salt intake,Urinary Sodium (mmol/2
7、4h),*,*,P0.001 reduced salt vs. usual salt intake.,Meta-analysis of Modest Salt Reduction Trials of one month or Longer,He 16:761-770,*,-2,0,-4,-6,100,50,150,0, Stroke 24%, CHD 18%,He 42:1093-99, salt intake 6g/day,USA 150,000 (approx) deaths prevented / year Worldwide 2.5 million (approx) Stroke &
8、Heart attack deaths prevented / year, Avg. 5 mmHg,Salt intake (10 12 g/day),Reduce salt intake,Population BP, rise in BP with age, hypertension,Other effects e.g. stomach cancer, stroke, LVH, kidney disease, osteoporosis etc,From 10 - 12 g/day to 5 - 6g/day,(WHO target 5g/day),Summary,WHO/FAO 2002.
9、www.who.int/hpr/NPH/docs/who_fao_experts_report.pdf,Table / Cooking (15%),Natural (5%),Food industry (80%),Current salt intake & sources of salt in UK (Similar in USA),Total 9.5 g/d (3.8 g sodium),1.4 g/d,0.5 g/d,7.6 g/d,Why is there so much salt in processed food?,James et al. Lancet. 1987;1:426-42
10、9.,SALT,Producers (40% by value),Food Industry Highly Salted Processed Food,Thirst ,Soft Drinks Mineral Water ,Profit,Profit,Dependence on salty taste (Salt Addiction),Demand for very saltyfoods ,Profit,Salt ,Salt ,Meat products + Salt,Salt ,Weight No Cost,Water Binding ,Profit,Hidden Salt Its Comme
11、rcial Value,He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.,Sea Water Comparison (1.0 g of sodium / 2.5g of salt per 100g),Pizza 60% Chicken Curry 60% Processed Cheese 130% Bacon 200% Sausages 100% Smoked Fish 190% Sweet Pickle 170% Shepherds Pie 40% Frozen Prawns 80% Crisps 110% S
12、alad Cream 100% Savoury Biscuits 70%,Medium Sliced White 50% Granary Loaf 60% Crumpets 80% Digestive 60% Cream Crackers 60% Cheddar Cheese 70% Stilton Cheese 90% Processed Cheese 130% Branflakes 100% Cornflakes 110% Tomato Ketchup 110% Brown Sauce 100%,Most have now been reduced by 10 30% (2008) in
13、the UK,Above data collected 2001,Japan,At this time Japan rapidly Westernised e.g. saturated fat, smoking, weight, exercise,1960 Government campaign to reduce salt intake,Akita (North): 18 14 g/day (4 g/day ),Overall: 13.5 12.1 g/day (1.4 g/day ),BP 80% in stroke mortality,Sasaki N. The salt factor
14、in apoplexy and hypertension: epidemiological studies in Japan. In: Yamori Y, editor. Prophylactic Approach to Hypertensive Diseases. New York: Raven Press; 1979. p. 467-74.,Year,Salt intake (g/day),Finland,Diastolic BP (mmHg),Stroke mortality (1/100000),Year,Year,Men,Women,Men,Women,Karppanen 49:59
15、-75.,Action in the UK Consensus Action on Salt & Health,Change Department of Health policy Ensure Food Standards Agency adopted salt reduction & labeling Media publicity to the public and food industry Persuade retailers and food companys to reduce salt added to food,Aims,www.actiononsalt.org.uk,Mem
16、bers all experts on salt and BP Set up 1996 in response to rejection of salt reduction recommendations by UK Dept. of Health,CASH Strategy for Reducing Salt in UK,Table/Cooking (15%),Natural (5%),Food industry (80%),0.9 g,0.5 g,4.6 g,40% reduction,No reduction,40% reduction,Salt intake,Reduction nee
17、ded,Total 9.5 g,1.4 g,0.5 g,7.6 g,Target 6.0 g, the food industry needs to reduce salt content of all foods by 40% over the next 5 years,Source,g/day,Target intake g/day,He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.,Sun newspaper 05/08/2004,Food Standards Agency (UK),Set up to de
18、al with BSE New variant CJD What else? salt reduction,Gradual repeated reductions in salt added to foods by 15%-25% Processed foods divided into 80 categories with targets set to be reached by the food industry in 2010 and 2012. Aim: To reduce salt intake to less than 6 g/d (adults) by 2012,www.food
19、.gov.uk,www.salt.gov.uk,Target set for levels of salt in key product categories 2006,www.food.gov.uk,Revised targets to be achieved by 2012 0.93g salt (370mg sodium) per 100g (avg),Traffic Light Label,GDA Label,Actions so far,Most processed foods have or will be reduced by 20-30% by 2010 More challe
20、nging targets have been set to be achieved by 2012 Foods eaten outside the home are now being addressed (e.g. canteens, restaurants, fast foods, takeaways, etc.) Aim: To reduce salt intake to less than 6 g/d (adults) by 2012,He & MacGregor. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.,Success s
21、o far UK,24h urinary sodium in a random sample of adult population has been reduced from the start of the program in 2003 to 2008 from 9.5 to 8.6 g/d of salt (10% ),(NB: on the background of an increasing salt intake),Approx. 6000 deaths - strokes, CHD prevented / yr,www.food.gov.uk,He 42:1093-99,Wo
22、rld Action on Salt & Health,366 members from 80 countries worldwide Worldwide Highlight foods high in salt Implement salt reduction Clear labeling system (traffic light)Individual countries Facilitate expert groups similar to CASH Convince government and health dept. & ensure action by food industry
23、 Public health campaign to salt consumption,,Target: Salt intake worldwide to 5g/d (WHO),Example sodium content around the world,USA Canada UK Australia McDonalds Big Mac (Sodium (mg) per portion) 1,040 1,020 840 960 Subway Italian BMT Sub (Sodium (mg) per portion) 1,770 1,670 1,700 1,470KFC Fillet
24、Burger (Sodium (mg) per portion) 1,230 1,250 1,200 1,265 Kelloggs Rice Krispies (Sodium (mg) /100g) 667 821 650 720,Source: Product websites 2009,WHO and EU Actions,WHO set up a Salt Action Network (SAN)To implement the EU framework for National Salt InitiativesThe goal salt intake less than 5 g/day
25、Initial activity - 12 food categories, e.g. bread, ready meals, breakfast cereals,24 countries now pledged to make a 16% salt reduction over 4 yrs,WHO Europe. http:/test.cp.euro.who.int/eprise/main/WHO/Progs/NUT/ActionPlan/20080516_1,Examples of actions in other countries,Australia AWASHs Public Hea
26、lth campaign starting to show resultsBangladesh National reduction supported by the National Heart Foundation Bulgaria Monitoring and evaluating programme for salt reduction initiativesCanada The Canadian Stroke Network has a full scale public health campaignCroatia CRASH: full national awareness ca
27、mpaignKenya Forming a Kenyan arm on WASH following a successful campaignMalta Launched a salt reduction initiative USA Have had strong recommendations since 1980s, with no results Salt Institute opposed any action (similar to Tobacco Manufactures Association) FDA Petition for salt as Generally recog
28、nised as safe to an additive has so far proved ineffective,,World Salt Awareness Week 2009,Participation from 28 countries around the world,Activities ranged from involvement from hypertension experts, representatives from the health and education ministries, consumers, the media and the food indust
29、ry.,Salt intake BP Salt intake biggest improvement in public health since clean water and drains (19th Century),Summary, Stroke Heart Attacks Heart Failure, Stomach Cancer & Osteoporosis,He & MacGregor. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. JHH 2008 on-line first. doi:10.1038/jhh.2008.144.,
