Stricter Regulations Needed to Maximize Cuts in Sodium Intake, UK Study Suggests

A public-private partnership geared toward reducing salt consumption that was in effect in the United Kingdom from 2011 to 2017 may be responsible for about 9,900 excess cases of cardiovascular disease when compared with what would have occurred under stricter regulations, a new study suggests.

Prior to the onset of this partnership, which was known as the Public Health Responsibility Deal (RD), the UK had a more stringent plan in place for reducing salt consumption. Running from 2003 to 2010, the earlier effort was known as the Food Standards Agency (FSA) salt-reduction strategy. The FSA developed mandatory targets for a 10% to 20% reduction in salt in packaged foods to be achieved by 2010 (later extended to 2012) and called for improved food labelling and educational campaigns to reduce the use of salt. Progress toward the goals was publicly documented, and both nongovernmental organizations and government officials maintained pressure on food companies.

The FSA included the threat of more onerous government regulation if the food industry did not reduce levels of sodium in packaged foods, while the RD—which came into effect after a change in political leadership—relied on industry to set and meet voluntary targets.

Such a sharp change in policy enables a natural assessment of the effects of the two different strategies. Compared with what was achieved under the RD, researchers led by Anthony A. Laverty, PhD (Imperial College London, England), found a greater level of salt reduction—and potentially more cases of CVD prevented—using the FSA strategy.

“The real overall message, I would say, is that you can’t rely on industry doing these things by themselves, because they don’t really have a particular incentive,” Laverty observed to TCTMD. “It’s not that they’re bad people, but if there isn’t a real reason for them to do it, they’re not going to go through this reformulation process.”

If we don’t change our direction, we’re going to go on paying the price in terms of dead bodies and people rolling into hospitals with heart attacks that they really do not deserve to have. Simon Capewell

The consequences of the more relaxed approach are severe, study co-author Simon Capewell, MD, DSc (University of Liverpool, England), suggested. “If we get a fair hearing, then I think the numbers speak for themselves,” he stated to TCTMD. “If we don’t change our direction, we’re going to go on paying the price in terms of dead bodies and people rolling into hospitals with heart attacks that they really do not deserve to have.”

Less Salt Reduction, More CVD

For the study, published online July 18, 2019, in the Journal of Epidemiology and Community Health, Laverty et al examined data from the National Diet and Nutrition survey of 2000-2001 and four national sodium surveys conducted between 2006 and 2014. They tracked the decline in sodium consumption over time.

In 2000-2001, mean salt intake was 10.5 grams/day in men and 8.0 grams/day in women. As the FSA strategy was developed, mean salt intake declined annually by 0.20 grams/day among men and by 0.12 grams/day among women. In the first 4 years under the RD, from 2011 to 2014, salt intake continued to drop but at a lesser rate—0.11 grams/day for men and 0.07 grams/day for women.

The real overall message, I would say, is that you can’t rely on industry doing these things by themselves, because they don’t really have a particular incentive. Anthony A. Laverty

Using a microsimulation model, researchers estimated the health impact of the flattened reduction in salt intake. The model, which incorporated data from the Office for National Statistics and the Health Survey for England, was used to develop two scenarios: one in which the decline in sodium consumption using the FSA strategy continued unchanged as though the RD never happened, and a second in which the flattening of the sodium intake decline seen in the RD continues until 2025.

Under the first scenario, researchers estimated that shifting to the level of salt consumption seen in the RD era yielded 9,900 cases of CVD, 710 CVD deaths, and 1,500 cases of gastric cancer that could have been prevented by maintaining reductions seen with the FSA strategy. Under the second scenario, maintaining RD levels until 2025 will yield an estimated 26,000 excess cases of CVD as well as 5,500 additional CVD deaths. A look across socioeconomic groups found that the poorest Brits fared modestly worse than their more affluent peers under the RD.

“Public-private partnerships such as the RD which lack robust and independent target setting, monitoring, and enforcement are unlikely to produce optimal health gains,” Laverty et al conclude.

Voluntary Targets Insufficient

On the same day this study was released, the New England Journal of Medicine published a perspective about the food industry’s responsibility for reducing sodium intake in the United States. One of its authors is James A. O’Hara III, MA, who served as the Deputy Assistant Secretary for Health under President Bill Clinton and then worked in various other government capacities until moving to the Center for Science in the Public Interest in 2014. O’Hara retired in 2018.

Commenting on the topic for TCTMD, O’Hara observed that “the need to reduce sodium has been clear for 40 years.” In 2016 the US Food and Drug Administration proposed voluntary salt reduction targets, similar to the UK model under the RD, he pointed out.

“It really is time for the Food and Drug Administration to move forward on its voluntary targets,” O’Hara continued. “We should see what the voluntary targets actually achieve. Do they achieve a reduction in sodium intake? And if they don’t, then other steps will need to be taken. It really is a matter of tens of thousands of Americans at risk each year for cardiovascular events because of high sodium intake, and we need to address this at the population level. And if the federal government fails to start acting as it was at least beginning to act in 2016, then industry should expect that local health departments and advocates will take action at the local and state level.”

The UK did not replace the RD with any new strategy after 2017, although a new public health approach is under development. The RD data suggest that a voluntary approach will not work, whether in the US or in the UK, Laverty suggested. “Salt intakes are still too high,” he said. “If average salt intake were more or less at the recommended level . . . then I think it would be easier to show that the voluntary [approach favored by the RD] was helping.”