Salt Reduction in the United Kingdom: a Successful Experiment in Public Health

REVIEW Salt reduction in the United Kingdom: a successful experiment in public health

FJ He1, HC Brinsden2 and GA MacGregor1

The United Kingdom has successfully implemented a salt reduction programme. We carried out a comprehensive analysis of the programme with an aim of providing a step-by-step guide of developing and implementing a national salt reduction strategy, which other countries could follow. The key components include (1) setting up an action group with strong leadership and scientific credibility; (2) determining salt intake by measuring 24-h urinary sodium, identifying the sources of salt by dietary record; (3) setting a target for population salt intake and developing a salt reduction strategy; (4) setting progressively lower salt targets for different categories of food, with a clear time frame for the industry to achieve; (5) working with the industry to reformulate food with less salt; (6) engaging and recruiting of ministerial support and potential threat of regulation by the Department of Health (DH); (7) clear nutritional labelling; (8) consumer awareness campaign; and (9) monitoring progress by (a) frequent surveys and media publicity of salt content in food, including naming and shaming, (b) repeated 24-h urinary sodium at 3–5 year intervals. Since the salt reduction programme started in 2003/2004, significant progress has been made as demonstrated by the reductions in salt content in many processed food and a 15% reduction in 24-h urinary sodium over 7 years (from 9.5 to 8.1 g per day, Po0.05). The UK salt reduction programme reduced the population’s salt intake by gradual reformulation on a voluntary basis. Several countries are following the United Kingdom’s lead. The challenge now is to engage other countries with appropriate local modifications. A reduction in salt intake worldwide will result in major public health improvements and cost savings.

Journal of Human Hypertension (2014) 28, 345–352; doi:10.1038/jhh.2013.105; published online 31 October 2013 Keywords: salt reduction; target; UK programme; public health

INTRODUCTION In 2003, the United Kingdom, through Consensus Action on Salt Evidence from various types of studies have consistently shown and Health (CASH), a non-governmental organisation (NGO), and that a high-salt intake increases blood pressure and thereby the Food Standards Agency (FSA), a quasi-government organisa- increases the risk of strokes, heart attacks, heart failure and kidney tion, developed a programme of voluntary salt reduction in disease.1–4 A high-salt intake also has other harmful effects on collaboration with the food industry. This has resulted in a fall in 14,15 16–18 health, for example, increasing the risk of stomach cancer5 and salt intake in the UK population. A few recent papers have linked to obesity through an increase in sugar-sweetened soft assessed the UK salt reduction policy and each of these papers has drink consumption.6 The current salt intake in most countries a particular focus on different aspects, for example, health 16 17 around the world is E9–12 g per day and a reduction in salt economics evaluation, the estimated changes in salt intake, 18 intake is considered one of the most cost-effective measures to the leadership and industry aspects. We have carried out a improve public health.7–9 As such, many national and international comprehensive analysis of the UK salt reduction programme with organisations have advocated for a reduction in population salt the aim of providing a simple step-by-step guide of developing, intake and recommended population-based intake targets, for implementing and monitoring a national salt reduction example, in the United Kingdom, the National Institute for Health programme that other countries can follow. and Clinical Excellence recommends o6 g per day by 2015 and a further reduction to 3 g per day by 2025.9 At the 2011 UN high- level meeting on non-communicable diseases, salt reduction was THE UK SALT REDUCTION STRATEGY listed as one of the top three priority actions to reduce premature We identiﬁed a number of key components of the UK salt mortality from non-communicable diseases by 25% by 2025.10,11 reduction programme (Figure 1) including (1) setting up an action The WHO (World Health Organisation), in its recent guideline group with strong leadership and scientiﬁc credibility; (January 2013), recommends a 30% reduction by 2025 with an (2) determining salt intake by measuring 24-h urinary sodium in eventual target of 5 g per day worldwide.12 Following on from this, a random sample of the population and identifying the major member states at the 66th World Health Assembly (25 May 2013) sources of salt in the diet by dietary record or recall; (3) setting a formally adopted these WHO salt targets as a part of an omnibus target for population salt intake and developing a salt reduction resolution to tackle non-communicable diseases.13 The question strategy; (4) setting progressively lower voluntary salt targets for now is ‘how should countries reduce salt intake in order to meet different categories of food, with a clear time frame for the food these targets’? industry to achieve; (5) working with and engaging the food

1Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK and 2Centre for Food Policy, City University, London, UK. Correspondence: Dr F He, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, London, UK. E-mail: [email protected] Received 22 July 2013; revised 3 September 2013; accepted 18 September 2014; published online 31 October 2013 Salt reduction: an experiment in public health FJ He et al 346 How to reduce salt intake in the population – The UK Model

Leadership and set up an action group (CASH)

Determine salt consumption (24h urine sodium) and sources of salt in diet (dietary method)

Set a target for population salt intake and develop a salt reduction strategy

Working with the food industry Public health campaign • Reduce salt added to processed, restaurant and fast food • Increase awareness of the harmful effects of salt • Set specific targets for each food category, with a clear on health time frame for industry to achieve • Do not add salt to food at the table • Voluntary, with threat of legislation • Do not add salt or ‘flavour enhancers’ made from • Praise the companies that make progress; Name and salt (e.g. stock cubes, soy sauce), when preparing shame those that do not take action food or during cooking • Clear nutritional labelling • Check food label choosing lower salt options

Monitoring progress and maintaining action in the long term • Regular survey of food products • Repeat 24h urinary sodium every 3 to 5 years • Reset targets for each food category every 2-3 years

Figure 1. An action framework of reducing salt intake in the population—The UK model.

industry to encourage reformulation of food to contain less salt to harmful to health and this resulted in the DH changing its stance meet these targets; (6) engaging and recruiting of ministerial on salt and finally endorsing the original recommendations of support and potential threat of regulation by the DH; committee on medical aspects of food policy to reduce salt (7) introducing clear labelling of salt content in food; (8) intake to o6 g per day. By working with several large super- conducting consumer awareness campaign; and (9) monitoring markets, for example, Asda, Marks & Spencer and Sainsbury’s, progress by (a) frequent surveys and media publicity of salt CASH was also able to successfully get them on board and to content in food, including naming and shaming, and (b) repeated start reducing salt content of their food. In 1999, the FSA was set 24-h urinary sodium at 3–5-year intervals. up primarily to deal with the aftermath of new variant Creutzfeldt-Jakob disease. Again, through lobbying Parliament and, in particular, the public health minister, CASH was able to Setting up an action group—CASH ensure, with the support of the then public health minister, Tessa In 1994, a review from the government’s advisory committee on Jowell, that the FSA took on the responsibility for salt reduction medical aspects of food policy to reduce cardiovascular disease as part of its nutrition work. The FSA then asked the Scientific recommended a reduction in salt intake to o6 g per day for the Advisory Committee on Nutrition to carry out a review on salt, UK adult population amongst many other recommendations.19 which confirmed that there was strong evidence to reduce salt In 1996, the UK government specifically rejected the intake in the whole population.23 Following this, the FSA and DH recommendations on salt because of pressure from the food made a commitment to work to reduce the salt intake of the UK industry who threatened to withdraw funding to the political population. party in power.20–22 In response, 22 experts on salt and blood Initially, CASH had no funds and work was done by research pressure (mainly drawn up from the committee on medical staff who were supported by other grants, putting in extra time. aspects of food policy) set up an action group—CASH. Within a few years CASH was successful in receiving donations. The aims of CASH were, and still remain, (1) to ensure the CASH became a charity in 2003 and since then has employed scientific evidence about the dangers of high-salt consumption three nutritionists for its work. Approximate expenditure since it becomes translated into policy; (2) to reach a consensus with the was founded in 1996 up to 2011 has been around d1 000 000. In food manufacturers and suppliers that there is strong evidence the 3 years leading up to 2011, this was also helped by a grant that salt is a major cause of raised blood pressure and has other from the British Heart Foundation for specific projects on reducing adverse health effects, and that they need to universally and salt eaten outside the home. gradually reduce the large and unnecessary amounts of salt that they add to food; and (3) to educate the public in becoming more salt aware in terms of understanding the impact of salt on their Determining population salt consumption, identifying sources of health, checking labels and avoiding products with high salt. salt in the diet and developing a salt reduction strategy CASH has been very successful in raising awareness of the An important step for all countries who want to develop a salt importance of salt reduction through strong leadership, scientific reduction policy is to determine the amount of salt consumed and input and utilising a wide range of advocacy tools including direct to identify the major sources of salt in the diet. The most reliable lobbying of MPs (Members of Parliament) and food industry via method of estimating dietary salt intake is to measure sodium meetings and letters, producing media statements and press excretion from 24-h urine collection, a method now endorsed by releases, carrying out research to enhance knowledge in the field, the WHO.24 Dietary methods such as dietary recall or dietary responding to consultations, collaborating with other stake- record are not accurate for determining salt intake but can be holders, holding parliamentary events and organising awareness used to identify the sources of salt in the diet, which then allows a activities directed to consumers.20 strategy to be developed, particularly focusing on the biggest The advocacy work of CASH was instrumental in ensuring that sources of salt in the diet, for example, in the United Kingdom, the Chief Medical Officer accepted that a high-salt intake is bread, processed meat products and cheese.25

Journal of Human Hypertension (2014) 345 – 352 & 2014 Macmillan Publishers Limited Salt reduction: an experiment in public health FJ He et al 347 the FSA have been working with all sectors of the food industry to Table 1. UK strategy for reducing salt intake engage, praise, cajole and, if necessary, shame manufactures to Salt intake Reduction Target intake ensure they reduce salt and meet the targets. As a result, nearly all needed (g per day) food manufacturers, retailers and trade associations, as well as Source g per day several catering companies have agreed to work towards the targets and started reformulation. Table/cooking (15%) 1.4 g 40% reduction 0.9 g Much of the publicity in the media is designed to influence Natural (5%) 0.5 g No reduction 0.5 g not only the public but also the management of the food industry as they are very concerned about being ‘named Food industry (80%) 7.6 g 40% reduction 4.6 g and shamed’ as the company that has the highest salt content Total: 9.5 g Target: 6.0 g of individual food, or is not pulling their weight in the salt reduction policy. CASH proposed the UK salt reduction strategy (Table 1) in 2003 based on an average salt intake of 9.5 g per day as calculated from Clear labelling of salt content in food 24-h urinary sodium in the National Diet and Nutrition Survey.25 Clear front of pack labelling of the salt content in food is essential From dietary record data,25 it was estimated that E15% of the salt for consumers to choose products with less salt. In the United consumed (that is, 1.4 g) was added by consumers either at the Kingdom, there are three main types of front of pack nutritional table or during cooking, 5% was naturally present in the food labelling: (1) a traffic light or colour-coding system where there is a (0.5 g) and the rest, E80% (7.6 g), was added by the food industry colour coding to show the levels of salt, fat, saturated fat and in processed food. In order to reach the target of 6 g, a total sugar, that is, low (green), medium (amber) and high (red). (2) A reduction of 3.5 g (that is, 40%) was needed. Therefore, the food guideline daily amount system where the amount per portion is industry would need to reduce the amount of salt added to all given as a percentage of the adult daily recommended maximum. food from 7.6 to 4.6 g (40% reduction) and the public would need (3) A hybrid model combining traffic light colours, the words ‘high, to reduce the amount of salt they add to food themselves from medium and low’ and guideline daily amounts. These three main 1.4 to 0.9 g (40% reduction). Any failure to reduce salt in a types have been widely used in various ways to label salt, such as particular food category would mean bigger reductions have to be salt per 100 g, salt per portion, sodium per 100 g and sodium per made in other categories. portion. If sodium (g) is on the label, then consumers have to multiply sodium by 2.5 to get salt (g). Such different labelling forms have caused confusion for consumers. Setting targets for different categories of food Independent research carried out by the FSA has shown that From 2004, the FSA with input from CASH and other stakeholders the traffic light labelling is preferred by consumers as they can see developed a model to look at the effects of reducing the average at a glance whether a product has a little or a lot of salt.31,32 salt content of different food categories on the population’s 26 Despite this, a significant part of the food industry has not salt intake. The model provided details for various food implemented this labelling and, indeed, strongly opposes any categories on the mean level of salt content, the amount of legislation on labelling. The European Parliament has also voted food consumed daily, their contribution to total salt intake and against making the traffic light labelling system mandatory in reductions needed in the salt content that would bring the Europe, and the shape of the final nutritional labelling legislation consumption down to the recommended level of 6 g per day. The is uncertain. first set of salt targets were published in March 2006 and devised CASH along with several other NGOs have campaigned for a for the industry to achieve by 2010 (that is, over a 4-year period). single front of pack nutrition labelling scheme, which includes They covered 85 categories of processed food that contribute 27 traffic light colour coding. In October 2012, the DH announced most salt to the diet. The aim was to implement a gradual that a consistent front of pack food labelling (that is, the hybrid stepwise reduction in salt added to food, for example, 10–20% labels) will be introduced in the United Kingdom in 2013.33 reduction and repeated at 1–2-year intervals. Such reductions are However, the scheme will still be voluntary. not detectable by human salt taste receptors28 and cause no safety and very few technical issues to the food in question, therefore posing no risk to sales and no rejection from consumers. Consumer awareness campaign Importantly, the food industry demanded a level-playing field so Another key component of the salt reduction programme is that all companies had to reduce the salt content in that particular consumer awareness. The public should be educated about the food category to the same salt target. These would be closely dangers of eating too much salt on their health, should be monitored and independently checked by the FSA, as well as encouraged to reduce the amount of salt they add to food at the surveys by CASH. table and during cooking and importantly to check product labels Since the targets were set in 2006, nearly all manufacturers and choosing lower-salt options. retailers have made significant reductions in the amount of salt In the United Kingdom, CASH has used various methods added to food.18 In 2008, the FSA revised the targets from 2010 to including regular press releases resulting in widespread 2012 to reflect this progress29 with even lower amounts of salt to media coverage, for example, television, radio, press and internet, 20 be added to processed food. It was envisaged at that time that as well as consumer resources to engage the public. In addition, further targets would be set in 2010, to run from 2012 to 2014, CASH has organised annual National Salt Awareness Week thereby giving the food industry 4 years to achieve. These targets since 2001 to raise awareness of the dangers of a high-salt would run progressively until the 6-g per day target for population diet and encourage local events to be held to highlight the salt intake is reached. importance of salt reduction. The week provides an opportunity for significant media coverage and the local events enable the message of salt reduction to reach those who would be otherwise Engaging with the food industry unaware of it. In most developed countries, E75–80% of salt in the diet is added Between 2004 and 2007, the FSA launched a three-stage to food at the stage of manufacturing.30 Therefore, to achieve a consumer awareness campaign.34 The first stage was to raise reduction in population salt intake, it is vital that the food industry awareness that too much salt is bad for health. The second stage reduces the amount of salt they add to all food. Both CASH and alerted adults to the fact that they should be consuming no more

& 2014 Macmillan Publishers Limited Journal of Human Hypertension (2014) 345 – 352 Salt reduction: an experiment in public health FJ He et al 348 than 6 g of salt per day. The final stage focused on the fact that per 100 g bread).38 In the latest CASH survey carried out in 2011,38 75% of salt consumed comes from processed food and therefore 144 out of the 203 (71%) products had reached the FSA 2012 salt consumers should check the labels. target for bread (that is, p1.0 g salt per 100 g bread).29 Following the FSA’s media campaign, an independent company Table 2 illustrates some examples of reductions in salt content carried out surveys in a UK representative sample of 2000 adults to for a selection of food categories. The data were collected as a evaluate the impact. The results showed that, from 2004 to 2009, part of CASH’s rolling survey programme, which aimed at the number of people who made an effort to cut down on salt monitoring the salt content of processed food sold in the UK increased by 26% (that is, from 34 to 43%), the number of supermarkets.39 Data were collected in store from nutrition panels consumers trying to reduce salt by checking labels increased by on the product packaging and from company websites. The 72% (that is, from 29 to 50%), and there was also a 10-fold surveys covered the leading supermarkets—Asda, Sainsbury’s, increase in the awareness of the 6-g per day target.35 However, Tesco, Waitrose, Marks & Spencer and The Co-operative. Among market research indicated that the FSA’s media campaign was not the food groups surveyed, all showed a decrease in salt levels, very effective in the long term, and incurred significant costs. An although there is a variation in the extent of reduction (Table 2). NGO like CASH could be much more effective and ensure a longer and more continuous media exposure at much less cost. Consumer salt use An analysis of the Health Survey for England data showed a steady decline in salt use at the table since 1997, and this reduction was PROGRESS MADE IN THE UNITED KINGDOM significantly greater after the introduction of the FSA’s salt Changes in salt content in food reduction campaign in 2003. The percentage of adults who add 40 Various sources of data, for example, product surveys, data salt at the table decreased from 32.5% in 2003 to 23.2% in 2007. collected from food companies, have consistently shown reductions in salt content in food. For instance, surveys carried out by Table and cooking salt sales the FSA and CASH showed that the average salt level of ready From 2004 to 2007, table and cooking salt sales in the United meals on sale in the UK supermarkets reduced by 45% from 2003 Kingdom decreased by E20%. Since 2007, more than 11 million 36 to 2007 (that is, from 3.3 to 1.8 g of salt per serving). kilograms of salt have been removed from food covered by the Bread is the single largest contributor of salt to the diet in the FSA’s salt reduction targets.41 United Kingdom, accounting for 18% of total salt intake from food.37 Surveys carried out by CASH and the FSA showed a Changes in mean population salt intake in England reduction in salt content of bread by 20% from 2001 to 2011 (Figure 2; with the average level reduced from 1.23 to 0.98 g salt The average salt intake, as measured by 24-h urinary sodium excretion in a random sample of the adult population, was 9.5 g per day in 2000/2001. Salt intake fell to 9.0 g per day in 2005/2006, Survey year (Number of products surveyed) 8.6 g per day in 2008 and fell further to 8.1 g per day by 2011.15 As 2001 2004 2005 2006 2007 2008 2009 2010 2011 24-h urinary sodium was not measured in 2003/2004 when the UK (40) (68) (20) (138) (48) (37) (58) (144) (203) salt reduction programme started, it is assumed that salt intake 1.6 was the same as that in 2000/2001. Therefore, from 2003/2004 to 1.5 2011, salt intake decreased by 1.4 g per day (that is, 15%, Po0.05 1.4 for the downwards trend).15 In other words, there has been a 1.3 steady fall in salt intake at a rate of E2% per year since the 1.2 introduction of the UK salt reduction strategy. As shown in Table 3, 1.1 the reduction occurred in both men and women, and in all age

(g/100g) 1.0 groups. (Mean±SD) Salt content 0.9 0.8 Estimated health and economic impact 0.7 Several cost-effective analyses have shown that salt reduction is 0.6 likely to be very cost-effective.7,8,16,42 In the United Kingdom, an Figure 2. Changes in salt content of bread sold in the UK analysis by the National Institute for Health and Clinical Excellence supermarkets from 2001 to 2011. showed that the UK salt reduction campaigns cost Ed15 million

Table 2. CASH surveys for a selection of food categories

Product First survey Second survey Reduction from ﬁrst to second survey Survey N Mean±s.d. (g salt Survey N Mean±s.d. (g salt year per 100 g) (Range) year per 100 g) (Range)

Breakfast cereals 2004 306 0.95±0.74 (0–3.68) 2011 290 0.41±0.39 (0–1.7) 57% (excluding porridge oats) Soup (wet) 2003 95 0.77±0.27 (0.25–2.5) 2010 462 0.54±0.13 (0.15–1.25) 30% Ketchup and brown sauce 2008 22 2.45±0.61 (1.08–3.5) 2010 30 1.57±0.70 (0.8–3.1) 36% Pies 2008 19 0.90±0.20 (0.5–1.2) 2011 251 0.72±0.21 (0.28–1.5) 20% Burgers 2008 24 1.13±0.36 (0.6–2.3) 2010 77 0.97±0.25 (0.5–2.0) 14% Processed cheese 2008 27 2.84±0.69 (1.8–4.3) 2010 44 2.17±0.50 (1.65–3.4) 24% Sweet biscuits 2007 175 0.77±0.32 (0–1.5) 2009 25 0.58±0.32 (0.1–1.1) 25% Abbreviation: CASH, Consensus action on salt and health.

Journal of Human Hypertension (2014) 345 – 352 & 2014 Macmillan Publishers Limited Salt reduction: an experiment in public health FJ He et al 349 Table 3. Salt intake as measured by 24-h urinary sodium excretion in adult population from 2000/2001 to 2011

2000/2001a 2005/2006a 2008a 2011a

N Mean±s.d. (g per day) N Mean±s.d. (g per day) N Mean±s.d. (g per day) N Mean±s.d. (g per day)

Men 19–34 214 11.3±5.21 33 10.3±3.87 46 10.0±4.21 43 9.5±4.03 35–49 170 11.1±4.83 67 10.1±3.90 111 9.50±4.06 84 10.0±3.86 50–64 183 10.5±4.95 88 10.2±4.19 137 9.30±3.00 123 8.2±4.79 All men 567 11.0±5.02 188 10.2±3.98 294 9.68±4.10 250 9.3±5.76

Women 19–34 189 8.8±4.60 49 8.6±2.99 61 8.3±3.38 43 7.1±3.23 35–49 203 8.0±3.42 99 7.9±2.7 157 7.41±2.86 101 6.8±3.07 50–64 187 7.5±3.45 112 6.8±2.8 180 6.97±3.00 153 6.6±3.47 All women 580 8.1±3.88 262 7.7±2.8 398 7.66±4.77 297 6.8±3.59

All 19–34 403 10.2±5.08 71 9.3±3.58 107 9.2±4.24 86 8.3±4.06 35–49 373 9.4±4.40 119 9.0±3.5 268 8.44±3.87 185 8.5±4.02 50–64 370 9.0±4.51 179 8.5±3.9 317 8.12±3.31 276 7.4±5.30 All 1147 9.5±4.71 350 9.0±3.7 692 8.64±4.39 547 8.1±5.79 aThe 2000/2001 survey was carried out in a random sample of adults in Great Britain, the 2008 survey was in a random sample of adults in the United Kingdom, and the 2005/2006 and 2011 surveys were random samples of adults in England.

and the 0.9-g per day reduction in salt intake achieved by 2008 led However, in October 2010, the DH directed by the Secretary of to E6000 fewer CVD deaths per year, saving the UK economy State for Health took responsibility for nutrition from the FSA. In Ed1.5 billion per annum.9,43 On the basis of the estimation of the March 2011, salt reduction was announced as one of the National Institute for Health and Clinical Excellence, the further public health goals to be included in a new initiative called the reduction of 0.5 g per day achieved by 2011 would prevent ‘Public Health Responsibility Deal’,45 which aims to bring together E3000 additional CVD deaths amounting to a total of E9000 public sector, academic, commercial and voluntary organisations. fewer CVD deaths per year. Further, there would also be E9000 The Responsibility Deal salt pledge adopted the FSA salt targets non-fatal CVD events prevented per year and greater cost savings for 2012 but made the industry responsible! The FSA had planned to the UK economy. to introduce a new set of targets in 2010 (to be met by 2014) but the DH failed to commit to plans for new targets until early 2013. This has meant a loss of momentum (3 years) in the salt reduction THE UK SALT REDUCTION—CHALLENGES AHEAD programme. Continuing efforts and new targets are Further, the FSA’s strategy provided an independent and urgently needed transparent monitoring programme to assess progress made Despite considerable reductions in salt content being made in towards the targets, whereas the Responsibility Deal allows many processed food and the resulting downward trend in salt companies to use their own monitoring format making it consumption, the mean population salt intake of 8.1 g per day is extremely difﬁcult to compare companies. Strong independent still 35% higher than the recommended level of 6 g per day, and and transparent monitoring, however, is vital in order to make a 70% of the adult population (80% men and 58% women) had a voluntary policy successful. daily salt intake above the recommended level.15 With the current The DH should enhance the FSA’s strategy with the introduction rate of 2% reduction per year, it would take another 12 years for of substantial disincentives for non-participation and sanctions for 46 the population salt intake to reach the target of 6 g per day. non-compliance, as well as a robust independent monitoring Therefore, continuing and greater efforts are needed, in particular, system. If the food industry refuses to comply, then regulation/ lower salt targets should be devised urgently. Taking bread as an legislation of the salt targets must be implemented. example, by 2011, 71% of bread products had already met the 29 FSA’s 2012 targets (that is, p1.0 g salt per 100 g bread). Technical feasibility and consumer acceptance Therefore, the target should now be revised down to 0.9 g o Technical feasibility and consumers’ taste acceptance of lower-salt per 100 g for the industry to achieve by 2014/2015. This is a food have been claimed as reasons for the lack of progress in realistic target in view of the fact that 27% of the bread products reducing salt in food by some sections of the food industry. surveyed in 2011 had salt levels already at or below this level. In However, the wide range of salt levels seen in similar range of March 2013, the DH announced its plan to revise the salt targets food that are already on the market (Table 2), many of which are for various categories of food by the end of the year.44 below the target, demonstrate that, technically, it is feasible to reduce salt levels further in almost all processed food. The transfer of salt reduction from the FSA to the DH Salt is a very poor preservative requiring a 15% concentration in in England the aqueous phase to inhibit bacterial growth and is now rarely The FSA has had an important role in the implementation of the used as a preservative as other chemicals are more effective. Salt is salt reduction policy, particularly as they were independent and used in combination with polyphosphate to bind water to meat free of political control. At the same time, they had considerable and ﬁsh products increasing the weight at very little cost, but power over the food industry in relation to food safety, making a other chemicals can now be used to increase water content if this voluntary policy likely to be successful. Without this and a forceful is really felt to be necessary by the food industry. In relation NGO, the salt reduction policy may not have been so successful. to taste, as salt intake falls, the salt taste receptors in the mouth

& 2014 Macmillan Publishers Limited Journal of Human Hypertension (2014) 345 – 352 Salt reduction: an experiment in public health FJ He et al 350 adapt and become more sensitive within 4–6 weeks. This and NGOs to ensure all companies are aware of the targets and means that lower concentrations of salt then taste as salty as make reductions to achieve the same low salt levels. It is also the previous higher concentrations, provided salt reduction is essential to have a monitoring strategy in place; for example, made by slow graded amounts by the entire food industry. repeated surveys of food products and 24-h urinary sodium. An Indeed, well-controlled studies have shown that once salt intake is important lesson learned from the UK programme is the need for reduced, individuals prefer food with less salt.47 The UK clear guidelines and targets for the catering sector as well as the experience indicates that, when the salt content in food is retail sector. gradually reduced, there have been very few complaints about the The UK salt reduction model could be used as a template by taste and no decrease in sales. most developed countries where the majority of salt in the diet is from processed food. Indeed, several countries, for example, the The catering sector United States, Canada and Australia are already adopting the United Kingdom’s model and setting their own voluntary targets The UK salt reduction programme has predominantly focused on for salt levels in processed food. Recently, South Africa has taken a food sold in supermarkets, and the catering sector is lagging regulatory approach to target setting and has done so with the behind. Most of the out-of-home food contain a disproportio- tacit support of the food industry to further ensure a ‘level-playing nately high amount of salt. For instance, CASH carried out a survey field’. in 2012 on pepperoni and margherita pizzas from takeaway outlets in 17 London Boroughs and 8 supermarkets.39 There were 81 types of pizza from takeaways and 118 from supermarkets. The Multinational companies—a global policy results showed that takeaway pizzas contained 45% more salt Salt reduction has been incorporated into many companies’ policies than the equivalent supermarket pizzas (1.57 vs 1.08 g salt per for the UK food market. These policies also ensure that new 100 g pizza, Po0.001) and, shockingly, a margherita pizza from products follow the salt targets. Multinational companies must now Pizza Express restaurant contained almost double the amount of apply a global policy to reduce the salt content of their products to salt compared with its equivalent in the supermarket (1.49 vs the lowest level in all countries where they are marketed. At the 39 0.85 g per 100g). moment, there is a very large variation in the amount of salt added In view of the fact that more and more people are eating out to the same branded products in different countries.51,52 For and the catering sector (that is, restaurants, takeaways, fast food example, a survey conducted by the World Action on Salt & outlets, caterers, canteens, prisons and hospitals) now provides Health—founded in 2005 based on the success of CASH, including 48 one in six (15%) meals, there is an urgent need for this part of over 260 branded products from KFC, McDonalds, Kellogg’s, Nestle, the food industry to get on board with salt reduction. In July 2012, Burger King and Subway in different countries,51 showed that every 45 the DH added three new salt pledges to the Responsibility Deal, product had a different salt content in different countries and no 49 with special focus on the catering sector. These pledges focus on one single product surveyed had the same salt level around the training and kitchen practice, reformulation and procurement. The world, with some showing large variations. For instance, Kellogg’s pledges commit companies to a 15% reduction in salt used in All Bran contained 2.15 g of salt per 100 g in Canada but only 0.65 g their kitchens, ensuring at least 50% of the products they procure of salt per 100 g just over the border in the United States, less than meet the 2012 targets within 1 year of sign up and increasing one-third of the Canadian level.51 This illustrates once again how further over time and/or reformulating the dishes with less salt. easy it would be for the food industry to reduce the amount of salt Immediately after the launch, 15 companies have signed up to at they add to food, particularly, as they could do this straightaway to 49 least one of these pledges. It is vital that the new salt targets their branded products. Pressure resulting from surveys such as this that are to be set in 2013 also apply to food eaten outside home has led to several large multinational manufacturers pledging to as similar food in the supermarkets ensuring a level-playing field. reduce the amount of salt added to food across the world. Those already committed to salt reduction worldwide include Pepsico, Salt intake in Scotland Unilever, Kellogg’s, Heinz, Campbell’s and Kraft, but how far they The 24-h urinary sodium data collected in 2006 suggested that salt have put this pledge into action is not clear. On the other hand, intake was higher in Scotland and lower in Wales compared with some international companies have exported their reduced salt that in England.15 A repeated measurement of 24-h urinary products manufactured for the United Kingdom to other European sodium in Scottish population in 2009 showed little reduction in markets without those countries being aware of the reduction in salt consumption.15 As the UK salt reduction strategy has been salt content. implemented in all UK countries, it is difficult to explain this difference between countries. It is possible that this may be partially due to a difference in socio-economic status or the VOLUNTARY VS REGULATORY/LEGISLATIVE APPROACH Scottish people may be eating out more often. Given the high The UK salt reduction programme has been carried out on a prevalence of hypertension and cardiovascular disease in voluntary basis, but this has been underpinned by sustained media Scotland, much greater input is needed from the devolved pressure, direct pressure on the government and ministers, Scottish government. It should be noted that Scotland is leading particularly the public health ministers, so that they would maintain the work in public health policies in the United Kingdom on a strong stance with the food industry. Regulatory/legislative tobacco and alcohol, and is soon to launch its own independent approaches are likely to be more effective than voluntary agency (that is, Scottish FSA) to focus on nutrition, food labelling approaches. For example, in Denmark, the move from voluntary and food safety.50 It is possible that Scotland could take the lead agreements on trans-fatty acid reduction to the successful on salt reduction in the future. implementation of a legislative ban of trans-fatty acid has led to rapid and large reductions in the trans-fatty acid content in processed food and margarines.53 However, in many countries, LESSONS LEARNED AND AN INTERNATIONAL PERSPECTIVE the process of legislation is very complicated and this may lead to The UK salt reduction strategy—a model for severe delays in action as demonstrated by the pace of tobacco other countries legislation (banning smoking in all workplaces) coming into force.54 One of the key factors contributing to the United Kingdom’s Countries therefore need to consider their own political success on salt reduction is setting progressively lower salt targets, processes to determine whether a regulatory/legislative or coupled with a forceful government or quasi-government agency voluntary approach is more appropriate. The best way to proceed

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An evaluation of the average salt intake of the population during the past 7 years at the UK Food Standards Agency’s salt campaign. Health Econ 2013; 22: 243–250. a small cost with potentially major health-care savings and 17 Millett C, Laverty AA, Stylianou N, Bibbins-Domingo K, Pape UJ. Impacts of a potential large reductions in the number of people suffering or national strategy to reduce population salt intake in England: serial cross sectional dying from strokes, heart attacks and heart failure. Indeed, the study. PLoS One 2012; 7: e29836. United Kingdom now has the lowest known salt intake of any 18 Wyness LA, Butriss JL, Stanner SA. Reducing the population’s sodium intake: the developed country as measured by 24-h urinary sodium.55 A key UK Food Standards Agency’s salt reduction programme. Public Health Nutr 2012; to success is the rigorous setting of progressively lower salt targets 15: 254–261. 19 Cardiovascular Review Group Committee. 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