Sugar, extra calories and obesity often dominate media headlines - heaping strain on over-stretched healthcare resources and keeping policy makers and researchers busy developing (cost) effective and politically palatable solutions. However, another food ingredient, salt, is silently taking lives each day, costing millions to both the NHS and society.
One major difference with sugar is that the path had been paved to effectively reduce salt intake, the UK was strolling happily down it, but regrettably stepped off. One in five deaths globally are attributable to poor diet, of which excess salt consumption (the NHS recommend adults consume no more than 6 grams per day) is the leading contributor.
Salt consumption is a leading risk factor for hypertension and many of the most common causes of death and disability in the UK, including stroke, heart attacks and kidney disease. Pleasingly, reducing salt intake can lead to health gains through reducing blood pressure in a short time frame (as little as 18 months), delivering savings to the NHS soon after.
With the majority of salt consumed coming from processed foods, just 18% from discretionary salt used in cooking or at the table, and palates adapting to reduced salt content over a short period of time, salt is a prime candidate for reformulation programmes.
In 2003, the UK initiated a nationwide salt reduction programme led by the Food Standards Agency. The programme took a voluntary approach, but with regular monitoring and incentivised compliance to agreed salt targets across more than 80 food groups. This approach worked.
By 2008, 19,700 tons of salt had been removed from our food. By 2011, average salt consumption had reduced by 15% from 9.5 grams a day to 8.1g and the National Institute for Health and Clinical Excellence (NICE) estimated this had saved the UK economy more than £1.5 billion per year.
By 2012, the UK had achieved the safest level of salt intake of any high-income country in the world with studies at the time estimating this could prevent approximately 20,000 strokes, heart attacks and heart failure cases a year, helping to reduce inequalities in several health conditions along the way. The success of this programme was such that tens of countries worldwide copied our ‘world-leading’ programme.
Regrettably, progress has since stalled. The flagship FSA salt programme was subsumed into Andrew Lansley’s Responsibility Deal which took a much more passive approach, with fewer carrots and almost no sticks, placing the entire responsibility on industry to self-monitor, before that too was dismantled with little or no success to report.
This came as no surprise to many. We have decades of evidence that policies incentivising industry change through carrots and sticks, rather than little more than passive direction, consistently achieve better and more equitable results. In fact industry themselves often report they favour programmes akin to mandatory reformulation, as these create a level playing field for the food industry and provide opportunity for innovation.
Recent research from Imperial College London and University of Liverpool that I was part of, estimated the health and economic cost to the UK of moving from the world leading FSA policy to the Coalition Government’s Responsibility Deal. This study found this change in policy had slowed the reduction in salt consumption sufficiently to contribute to 9,900 additional cases of cardiovascular disease, and 1500 additional cases of stomach cancer from 2011-2017.
Even more worryingly, the study estimated that without urgent action, this ‘looser’ approach to salt reformulation could lead to an additional 26,000 cases of cardiovascular disease, and 3,800 cases of stomach cancer between 2019 and 2025, costing almost £1 billion to the NHS and wider economy over this period.
The Responsibility Deal failed, but ending it in itself is not enough to compensate for lost time and lives that were preventable. In December last year Public Health England released their latest analysis of industry progress on salt; targets for just 50% of foods had been met, and consumption hovered around 8grams – the new approach is not working as effectively or swiftly as its predecessor.
This is not surprising given the precedence of the flagship sugar reduction policy which also fell short of its first year targets. In his vision paper, ‘Prevention is better than cure’, Matt Hancock highlighted salt as a key policy target and his commitment to build upon past success in reducing consumption.
The recently published prevention green paper, whilst light on firm commitments, offers hope with the commitment to publish revised salt targets in 2020. These must be ambitious targets, with incentives and disincentives to ensure industry compliance. We can and must learn from past public health challenges and successes.
As wider discussion of scrapping of Lansley’s NHS reforms gains momentum, re-instating the world-leading, ambitious salt reduction programme that the same previous health secretary abolished, offers as low hanging fruit to deliver rapid and fair health gains to thousands of individuals, helping to support NHS finances. Here’s hoping we can put salt back on the policy table, so we can remove it from our diets and reduce avoidable deaths and disability from our society.