WASH Comment on WHO 2nd discussion paper on the monitoring framework and targets for the prevention and control of NCDs

19 April 2012

World Action on Salt and Health is deeply disappointed, after several years of discussion and consultation where a salt target of 5g per day has been agreed as an appropriate target to have the maximum impact on reducing the global burden of NCDs, to see this now being eroded in parts of the document to a 30% salt reduction target. This is a major step backwards; it is clear that the power of the global food industry are influencing decisions, and compromising our health.

The WHO set a salt target of less than 5 gram a day in 1983, which was further endorsed in 2003 [1] and 2006 [2]. This 5g salt target has long been referenced as the interim target to achieve a population wide reduction in salt intake to reduce the global burden of Non Communicable Disease (NCDs). It is therefore with deep disappointment at this stage in the consultation process that WHO has now suggested to dilute the 5g target to a salt reduction target of 30%. Although the 5g target remains within the text of the document, the 30% reduction target is extremely misleading as this percentage reduction will not achieve a 5g target in all countries around the world.

At the same time, for most developing countries, it is not known what current salt intakes are, and so a 30% reduction is meaningless, and serves to hinder rather than support action in this area. The 5g target was agreed based upon evidence which showed the maximum benefit to all countries around the world.

Many countries around the world have already adopted the WHO 5g target. Canada, Australia and the United States all have salt reduction targets of 4 [3], 5 or 6 gram a day [3], and more recently South Africa ahead of the UN Summit in September 2011. Similar targets have also been set across the EU (e.g. UK 6 gram a day [4]).

Stipulating a 30% salt reduction target as a stand-alone target will dilute current efforts to reduce population level salt intake on a global scale, it will also impede efforts to stimulate the global food industry to reduce salt in all food, sold in all markets around the world.
If the 30% salt reduction target is to remain in this document, it should be clearly defined as a first step towards bringing about a reduction of salt intake in all populations to less than 5g per day for adults, and less for children. This must be explicitly stated throughout the documents, wherever the 30% reduction is referenced.

Furthermore, a salt reduction target of less than 5g must be set for children. This has not been clarified in this document, whereas the UK and several other countries have set targets for children. This is a very important point, as blood pressure starts to rise early in childhood, due to the excess salt intake.
It is vital that targets are clear and consistent, and that a worldwide target is set for all countries. It is clearly inequitable that different countries should have vastly different targets, when the 5g target has already been established to have the maximum benefit.
The 5g target is achievable with the combination of reducing the excessive and unnecessary amounts of salt put into food by the food industry and by individuals taking their own measures to cut their salt intake. In fact this 5g target is probably, of all the targets for NCDs, the easiest to achieve by 2025, and certainly will be achieved in all developed countries.

The constitution of the WHO clearly states ‘Health for all’. This should be strongly considered when setting targets worldwide ensuring that all countries are able to obtain maximum benefits from efforts to reduce the global burden of NCDs. Percentage reduction targets do not offer this opportunity.

Notes:
Worldwide current intakes, where known, are wide spread; they range between 5 and 15g (Webster et al, 2011); it is estimated that a reduction of 6g/day in salt intake would prevent approximately 2.5 million strokes and coronary heart disease deaths a year (He & Macgregor 2009).
Salt puts up our blood pressure, which is the leading cause worldwide of death and disability through the strokes, heart disease it causes. Salt reduction is the simplest and most cost effective measure to reduce NCDs and it is more cost effective than tobacco control for both developed and developing countries [Ref 2 & 3 NICE and Asaria].

References:
1. Joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases, 2003, Geneva. www.who.int/hpr/NPH/docs/who_fao_experts_report.pdf
2. World Health Organization. Reducing salt intake in populations. Report of a WHO Forum and Technical meeting 5–7 October 2006, Paris, France. http://www.who.int/dietphysicalactivity/reducingsaltintake_ EN.pdf.
3. Institute of Medicine Strategies to Reduce Sodium Intake in the United States. www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-in-the-United-States.aspx.
4. Scientific Advisory Committee on Nutrition, Salt and Health. 2003. The Stationery Office. www.sacn.gov.uk/pdfs/sacn_salt_final.pdf
5. National Institute for Health and Clinical Excellence (NICE). Guidance on the prevention of cardiovascular disease at the population level. http://guidance.nice.org.uk/PH25
6. 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.
7. He FJ, MacGregor GA (2009) A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens; 23 : 363–84.
8. Webster JL, Dunford EK, Hawkes C, Neal BC (2011) Salt Reduction Initiatives around the world. Journal of Hypertension. Vol 29: 1043-1050