1

STRENGTHENING PREVENTION OF NON-COMMUNICABLE DISEASES IN LOW- AND

MIDDLE-INCOME COUNTRIES

Dietary Policy Interventions in NCD : Salt Reduction (SHAKE)

Rome, Italy, 17 March 2016

Dr Temo Waqanivalu Team Leader, Population-based Prevention Prevention of NCD

2

Agenda

• Overview

• Burden of NCD risk factors: Salt and HTN

• WHO Technical Packages and Tools

– SHAKE

• Potential collaboration with Italy

3

WHO NCD Targets by 2025

Av 10g salt/day

Av 22%

4

Strong evidence for the link between salt and health

Source: He et al. J Human Hypertension, 2008

Primarily linked with CVD

– Sodium consumption increases BP

– BP increases CVD risk

– Age, sex and baseline BP specific effects

Also associated with:

left ventricular hypertrophy, kidney disease, renal stones, osteoporosis, gastric cancer

5

Prevalence of Raised Blood Pressure

• Global Prevalence 22% (2014) • Causes est 9.4 million global deaths

6

Prevalence of Raised Blood Pressure

Burkina Faso 25.1%; Senegal 24.2% Sudan 24.4%

7

Salt Intake

63

are sparse and are based on food-consumption data rather than on more accurate measures of

sodium excretion.

Fig. 4.1 Mean sodium intake in persons aged 20 years and over, comparable estimates,

2010

Monitoring population intake of salt/sodium The indicator for monitoring this target is age-standardized mean population intake of salt (sodium

chloride) in grams per day in persons aged 18 years and over (13). Few countries have a baseline

level of population salt/sodium intake, or knowledge of the most common sources of sodium in the

diet. Data need to be gathered from a population-based (preferably nationally representative)

survey, either as a stand-alone survey or as part of an existing one. For instance, in many countries a

subsample of the population used for the NCD STEPS survey (14) is used to estimate data on salt

consumption. The recommended standard for estimating salt intake is 24-h urine collection;

however, other methods such as spot urine, single morning fasting urine and food frequency surveys

have been used to obtain provisional estimates. There may be wide differences in sodium intake

within countries, especially in emerging economies and in countries with rapidly increasing

urbanization and peri-urban populations.

Progress achieved National efforts to reduce population salt consumption are under way in many countries (15–17)

(see Boxes 4.1–4.5). Following implementation of national strategies to reduce sodium in

Comment [mendiss10] : ***

•Average 10g salt/day •WHO Recommendation <5g salt/day

Mean Sodium Intake in persons 20 yrs and over 2010

8

Salt Reduction saves lives

9

Reducing salt intake is a Very Cost Effective (Best Buy) Intervention

Reduce salt intake in food

10

SHAKE technical package for salt reduction

• Identifies the key policies/interventions for salt reduction (technical package)

• Guidance on how to develop a national salt reduction strategy and implement the key interventions (toolkit)

• Global applicability

• Field tested in all regions

11

12

13

Mongolia

2011 MoH launched salt reduction initiative

Baseline data on salt intake (demographics, KAB related to salt, health, dietary recall, 24h urine)

Av salt intake estimated 11.06g/d (mainly from salted tea, sausage, smoked meats, pickled vegetables, bread and chips)

Pilot initiatives

– salt reduction in factory meals : ↓ intake by 2.8g

– and bread : ↓salt content by 1.6%

14

Select the food categories and determine baseline salt

content

Targets of salt content for different food categories i.e.

breads, cheeses etc.

Set targets as averages/means, or maxima; ideally both

Targets can be voluntary or mandatory

Propose a schedule of targets and timelines for

discussion

15

Kuwait

4 keys steps in partnership with industry:

1. Educate companies on methods for reducing salt and population benefits

2. Emphasise key role of private sector

3. Determine levels of sodium in local products

4. Create collaborative plan

Reduce salt in bread by 20% in first year

16

17

•Identify behavioural objectives

Objectives

•Conduct situational market analysis

Barriers & facilitators •Design a

communication strategy

Five pointed star of action

•Prepare implementation plan & budget

Detailed plan for strategy •Evaluate the

strategy

Impact & lessons learnt

18

Viet Nam and Australia

Communication & Education strategy 1. Administrative mobilization and public

advocacy

2. Community mobilization

3. Advertising

4. Face-to-face engagement

5. Point of service promotion

Reduce salt intake from 15.5 to 13.3 g/day

19

Caterers and food outlets

Schools

Hospitals

Faith-based organizations

Workplaces (public and

private)

Army/Police/Prisons

20

Shandong, China

SMASH Initiative worked though local govt agencies and health teams at households, school and restaurants settings

o developed salt standards

o trained chefs

o produced lower salt menus

o communications to increase knowledge and raise awareness.

Mid-term evaluation estimate reduction salt use

21

Country Progress

Voluntary salt targets Mandatory salt targets Regulation on

labelling

Tax on high salt

products

Use of

Potassium

enriched salt

Reformulation of

restaurant menus

Argentina

Australia

Austria (bread) *

Belgium

Brazil

Bulgaria

Canada

Chile

Denmark

Ireland

Italy (bread) *

Lithuania *

Mexico (bread) *

Poland *

Slovenia

Spain

UK

USA

Argentina

Belgium (bread)

Bulgaria (bread, milk

products & lutenica)

Brazil (mozarella

cheese and cheese

spreads) [soups]

Hungary (bread)

Netherlands (bread)

Portugal (bread)

Paraguay (bread)

South Africa

Finland Hungary

Portugal

China Singapore

USA (National

Salt Reduction

Initiative )

* targets for percentage reduction for food categories over time period rather than max/average levels of salt

22

Potential collaboration

• With tools developed next phase is to build capacity in country and regions to help scale up action to reduce salt, prevent and control raised blood pressure and CVD

• Country Prioritization exercise is being carried out in terms of CHD/stroke, population size, political readiness with priority given to lower middle income countries

• Great opportunity on joint work in the Africa region

– High intake of salt

– Highest average raised blood pressure

– Population based prevention highly cost-effective to reduce salt, prevent & control CVD & NCD and save lives

– Preventing the next crisis in addition of putting out the last fire in Africa

23

Thank you waqanivalut@who.int

http://www.who.int/dietphysicalactivity/en/