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Salt - intake, reduction and regulation in South Africa Melvyn Freeman Cluster Manager Non-communicable Diseases.

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Presentation on theme: "Salt - intake, reduction and regulation in South Africa Melvyn Freeman Cluster Manager Non-communicable Diseases."— Presentation transcript:

1 Salt - intake, reduction and regulation in South Africa Melvyn Freeman Cluster Manager Non-communicable Diseases

2 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.

3 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.

4 According to the latest Stats SA mortality statistics, diseases of the circulatory system are the second highest cause of all deaths in South Africa.

5 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.

6 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...


8 Major Underlying Factors causing Death - Worldwide Ezzati et al. Lancet 2002:360:1347-60. Underweight Unsafe sex High cholesterol Tobacco Raised Blood Pressure 0 1234567 Millions of Deaths 7 million Developing region Developed region Raised BP is responsible for 62% of all Strokes 49% of all Heart Disease


10 Atheroma in carotid artery Plaque Ulcerated Plaque Fissured Plaque with Thrombosis

11 What puts up population BP? Salt intake Lack of Fruit and vegetables Weight Lack of Exercise (Alcohol excess)

12 1263 Salt Intake (g/day) Systolic BP (mmHg) Diastolic BP (mmHg) Urinary Sodium (mmol/24h) 50 100 150 200 0 100 90 150 160 155 145 95 165 Randomised Double-Blind Crossover Study (N=20) MacGregor et al. Lancet 1989;2:1244-7. P<0.001 by repeated measures ANOVA.

13 HypertensiveNormotensive Fall in Systolic BP (mmHg) Usual salt intake Reduced salt intake Urinary Sodium (mmol/24h) *** P<0.001 reduced salt vs. usual salt intake. Meta-analysis of Modest Salt Reduction Trials of one month or Longer J Hum Hypertens. 2002;16:761-770 *** -2 0 -4 -6 100 50 150 0

14 Change in Systolic BP (mmHg) Change in Urinary Sodium (mmol/24h) Hypertensives b=0.07, P<0.001 Normotensives b=0.04, P<0.001 Dose Response: Meta-analysis (1 month or longer)  A 6 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) J Human Hypertens 2002;16:761  Avg. 5 mmHg

15  Salt intake 5-6g/day  Stroke 24%  CHD 18% Worldwide 2.5 million (approx) deaths prevented / year He & MacGregor. Hypertension 2003;42:1093-99 35,000 (approx) Stroke & heart attack deaths prevented / year UK

16 Outcome trial  25% Salt intake (↓2.5 g/d)   25% CVD events

17 Year Salt intake (g/day) Finland Diastolic BP (mmHg) Stroke mortality (1/100000) Year Men Women Men Women Karppanen & Mervaala. Prog Cardiovasc Dis 2006;49:59-75.

18 Fantastic for Public Health Very little cost Food industry slowly reduce - No rejection by public No need to change diet Hidden Salt in food e.g. processed, fast, takeaway, restaurant food ↓ BP

19 Perceived Barriers 1.Taste 2.Food technology 3.Safety 4.Commercial


21 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.

22 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.

23 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.

24 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?

25 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.

26 Foodstuff category Maximum Total Sodium per 100 g foodstuff Date on which the total Sodium reduction becomes effective 30 June 2014 30 June 2017

27 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

28 All breakfast cereals, including hot oat and other hot and instant porridges All margarines and fat spreads Table butter Ready-to-eat savoury snacks

29 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

30 Definitions “bread” means white bread, brown bread, whole- wheat 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;

31 “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;

32 "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;

33 “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.

34 “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.

35 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.

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