Consultation on the thirteenth General Programme of Work (GPW13)

The WHO currently has an open consultation on their thirteenth General Programme of Work (GPW13). Within their Impact Framework, population-wide salt reduction programmes are no longer a priority, as they were within GPW12. 

Instead, the WHO states that its role is to: “Implement the Global Hearts Initiative to Reduce Heart Attacks and Strokes. Support the implementation of the HEARTS and SHAKE technical packages in at least 20 low- and middle-income countries where the burden of cardiovascular diseases is highest” under the hypertension target ‘Reduce prevalence of raised blood pressure by 20%’.  There is now no mention of the population salt reduction target of 30% by 2025.

While the Global Hearts Initiative does encompass salt reduction activities, it also involves better management of CVD and tobacco reduction, and the SHAKE technical package is only mentioned in relation to low- and middle-income countries. This suggests a move in focus to better management of NCDs related to salt intake, as opposed to vitally important preventive actions such as population-wide salt reduction.

Professor Graham MacGregor, chairman of WASH, provided the following response:

Thank you for the opportunity to respond to the draft 13th General Programme of Work 2019-2023. This submission represents the views of our UK NGO Consensus Action on Salt & Health (CASH) which, along with the UK Food Standards Agency and now Public Health England, has been instrumental in reducing salt intake in the UK population, with a consequent reduction in population blood pressure and major reductions in people suffering and dying from strokes and heart attacks [1]. The submission also represents views of the 500 members in over 100 countries from our World Action on Salt & Health (WASH) organisation, which has successfully helped set up salt reduction programmes in many countries around the world.

We are very concerned to see there is no mention of salt/sodium reduction within Goal 3 of the Programme of Work’s proposed Health Priorities, particularly as the WHO currently has an existing target of 30% relative reduction in mean population sodium intake by 2025 [2,3], with an eventual WHO recommended salt target of less that 5g/day [4,5]. We are at a complete loss to understand why this critical non-communicable disease (NCD) target has been removed, for the following reasons:

1) Salt reduction has been shown in the UK by the National Institute of Clinical Excellence to be the single most cost effective public health intervention programme, with many other studies supporting this finding [6]. Indeed one study showed that in lower and middle income countries, salt reduction was more cost effective than tobacco control in terms of reducing cardiovascular disease (CVD) [7].

2) The WHO has previously recommended salt reduction as one of its top best buys to prevent death and disability from NCD’s, due not only to its cost effectiveness, but its feasibility [8]. And this has been clearly demonstrated by an ever growing body of successful salt reduction programmes from many countries across the world.

3) Furthermore in many developing countries, existing resources are not sufficient for comprehensive programmes to seek out and treat high blood pressure. Whereas public health salt reduction programmes in many of these settings are entirely feasible, e.g. rural China, rural India.

4) The risk of raised blood pressure starts at a systolic of 115mmHg, but high blood pressure is not defined until systolic is 140mmHg. As the majority of the global population fall between 115 and 140, although the risk is lower than that for raised blood pressure, the number of deaths attributable to blood pressure is as great from 115-140 as >140. Therefore it is vital that any WHO policy tackling the single biggest cause of death and disability in the world (raised blood pressure) must not only include better detection and treatment of high blood pressure, but also policies to lower population blood pressure and prevent the development of hypertension. The most cost effective and feasible policy is salt reduction, which will cause not only reductions in strokes and heart disease in those with high blood pressure, but also prevent just as many strokes and heart attacks in those who would not conventionally be treated but are otherwise at increased risk.

5) Failing to include a separate target for salt reduction would also fail to acknowledge its major contribution to the development of osteoporosis, gastric cancer, obesity and kidney disease.

Almost 50% of WHO member states now have or are in the process of setting up a salt reduction policy. A recent analysis showed that 23 countries had salt reduction targets in place, 14 of which are voluntary and 9 regulated. Plans are actively being implemented to reduce salt in many low- and middle-income countries in all of the WHO regions, e.g. Jordan, Morocco, China and Vietnam.

It would therefore be a tragedy, given that salt reduction has been one of the most successful and achievable targets set by the WHO for the prevention of NCD’s, to downplay it as the current programme suggests. Indeed much of the progress in salt reduction has been made based on good support from the WHO and we fear that momentum would be lost if it was no longer part of the latest WHO programme of work.

Putting salt reduction somewhere within the small print to achieve the 20% reduction in blood pressure would mean that this simple, measurable, feasible and very cost effective action will slip down the list of public health priorities for developing and developed nations.  We therefore ask that the 13th programme of work reflect the priorities as set out in the Global Monitoring Framework. If not, many millions of lives will be lost and affected by an increased burden of illness from strokes and heart disease.

[1] He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality BMJ Open 2014;4: e004549. doi:10.1136/bmjopen-2013-004549
[2] World Health Organization. WHO Global NCD Action Plan 2013-2020. WHO Geneva, 2013; pp. 1-102
[3] http://www.who.int/nmh/publications/ncd-infographic-2014.pdf?ua=1
[4] Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl J. Effect of lower sodium intake on health outcomes: systematic review and meta-analyses. Br Med J 2013; 346: f1326
[5] World Health Organization. Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO), 2012, pp.1-56
[6] Webb M, Fahimi S, Singh GM et al. Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations. BMJ 2017;356:i6699
[7] Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044-53.
[8] World Health Organization. From Burden to “Best Buys”: Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries. http://www.who.int/nmh/publications/best_buys_summary.pdf

The consultation can be viewed here.