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Graham MacGregor
Professor of Cardiovascular Medicine
Wolfson Institute of Preventive Medicine,
Barts and The London School of Medicine & Dentistry,
Queen Mary University of London, UK
Salt, Sugar & Fat
Major Underlying Factors Causing Death - Worldwide
GBD 2013 Risk Factors Collaborators. Lancet 2015;385:117
Number of Deaths in thousands
0 2,000 4,000 6,000 8,000 10,000 12,000
Sexual abuse and violence
Low bone mineral density
Occupational risks
Other environmental risks
Unsafe water, sanitation, and handwashing
Unsafe sex
Child and maternal malnutrition
Low GFR
Low physical activity
High total cholesterol
Alcohol and drug use
High fasting plasma glucose
High BMI
Air pollution
Tobacco smoke
High systolic BP
Dietary risks
0 2,000 4,000 6,000 8,000 10,000 12,000
Sexual abuse and violence
Low bone mineral density
Occupational risks
Other environmental risks
Unsafe water, sanitation, and handwashing
Unsafe sex
Child and maternal malnutrition
Low GFR
Low physical activity
High total cholesterol
Alcohol and drug use
High fasting plasma glucose
High BMI
Air pollution
Tobacco smoke
High systolic BP
Dietary risks
Unhealthy diet
High systolic BP
High BMI
High plasma glucose
High cholesterol
Processed foods and soft drinks
Fat (saturated)Sugar
Calorie
Dental
caries
Cholesterol Blood PressureObesity
Type 2
Diabetes
Cancer
Salt
Heart disease
Stroke
Systolic BP & Stroke Deaths
Systolic BP (mmHg)
The risk starts at systolic 115 mmHg (83% adults)
120 125 135 148 168
2
4
8
16
32
Risk
MacMahon et al. Lancet 1990;335:765-74
Cerebral haemorrhage
Mid line shift due to raised pressure
Brain (cross section)
Atheroma in carotid artery
Plaque
Ulcerated
Plaque
Fissured Plaque
with Thrombosis
Strategy
Reduction in
population BP
Better control of
raised BP
Massive Reduction in
Strokes, Heart Failure, Heart
attacks
BP – 2nd biggest cause of death in the world
What puts up population BP?
• Salt intake
• Lack of Fruit and vegetables
• Weight
• Lack of Exercise
• (Alcohol excess)
CASH Strategy for Reducing Salt in UK
(2003)
www.actiononsalt.org.uk
Table/Cooking (15%)
Natural (5%)
Food industry (80%)
0.9
0.5
4.6
40% reduction
No reduction
40% reduction
Salt intake Reduction needed
9.5
1.4
0.5
7.6
6.0
Source g/d
Target intakeg/d
Total
Fantastic for Public Health
Very little
cost
Food industry slowly reduce
- No rejection by public
No need to
change diet
Hidden Salt in foode.g. processed, fast, takeaway, restaurant food
↓ BP
The voluntary ‘carrot and stick’
approach
food industry
www.actiononsalt.org.uk
0.6
0.7
0.8
0.9
1.0
1.1
1.2
1.3
1.4
1.5
1.6
Impact of incremental targets
on salt in bread
He et al. JHH 2014;28:345
Target(g/100g)
1.1 20101.0 20120.9 2017
***
***
***
***
7
8
9
10
*
50
100
150
200
250
126
128
130
132
70
72
74
76
Deaths
per
100,000
per year
Blood
pressure
(mmHg)
Salt intake
(g/d)(from 24h UNa)
IHD
Stroke
2003 2006 2008 2011
Salt Intake, BP and CVD Mortality in England 2003─2011
He et al. BMJ Open 2014;
4:e004549
* P<0.05
*** P<0.001
≈18,000
(9,000 fatal)
CVDs
prevented
NICE: http://guidance.nice.org.uk/PH25
≈ £1.5 billion
healthcare
savings
per year
Countries with salt targets
Argentina
Belgium
Bulgaria
Chile
Greece
Hungary
Netherlands
Paraguay
Portugal
South Africa
(29/30 companies preferred regulation)
RegulatedVoluntaryAustralia
Brazil
Canada
Ireland
Italy
Kuwait
New Zealand
Norway
Poland
Turkey
UK
USA
Why are we getting so fat?
11 bananas or 18 oranges
or half a marathon
A Big Mac, large
chips and coca cola
Food/soft drink industry
Calorie-dense
Cheap
Profitable
Transient
satiation/
fullness
Calorie intake ↑
Obesity/type 2 diabetes ↑
“Brilliant” marketing
Any time
Everywhere
Eat more
Consequence of Obesity
• Type 2 Diabetes
• CVD (↑BP, cholesterol)
• Cancer (Breast; Colon;
Uterus; Esophagus;
Kidney; Pancreas)
• Fatty liver
• Osteoarthritis
Who is responsible?
• Public
• Government
• Food industry
Food industry must reduce salt, fat
& sugar content of foods
Change food environment
• Reformulation Voluntary/regulatory
• Ban unhealthy food advertising &
promotions
• Tax - High salt, sugar, fat foods
• Subsidise healthy food, e.g. fruit & veg
• Restrict availability
• Reduce portion size
Sugar- Impact on health
• The major cause of dental decay
(caries)
• Major source of hidden & empty
calories
• Leads to obesity & diabetes
• Direct toxic effects?
Added Sugar Similar to Salt
• Pure, white
• Makes inedible food palatable
• Only recently part of human diet
• Sensitivity of taste receptor depends
on intake
• Hidden
Hidden Sugar (tsp)
x11
x9
x7
x6
x4
x6
x5
x4
Sugar: Spinning a web of influence
• Liquid: easy to reduce
• Solid: ↓portion size, polyols, insoluble fibre
• Incremental targets, aim 50% reduction
• Artificial sweeteners?: Need to ↓sweetness
Incremental sugar targets like salt
This will ↓calorie intake by >100 Kcal/person/d
Bat
ten
be
rg
Ge
no
a
Re
d v
elv
et
Lem
on
Sw
iss
roll
Ch
oco
late
cak
e b
ar
Gin
ger
Cu
pca
ke/f
airy
cak
es
Fru
it S
wis
s ro
ll
Co
con
ut
Ice
d M
ade
ira
Bro
wn
ies
Fru
it
Ch
oco
late
Sw
iss
roll
Vic
tori
a
Co
ffe
e a
nd
wal
nu
t
Fru
ite
d M
ade
ira
Bak
ew
ell
Lem
on
Car
rot
Wh
ite
ch
oco
late
Alm
on
d
An
gel
Ch
oco
late
Co
ffe
e
Wal
nu
t
Ch
oco
late
mu
ffin
s
Mad
eir
a
Pla
in w
ith
ch
oco
late
Blu
eb
err
y m
uff
ins
Sugars(g/100g)
Different cakes
Sugar in cakes
Pla
in w
ith
ch
oco
late
Ch
oco
late
cak
e b
ar
Cu
pca
ke/f
air
y ca
kes
Co
ffe
e an
d w
aln
ut
Red
vel
vet
Ch
oco
late
Bro
wn
ies
Wh
ite
ch
oco
late
Ch
oco
late
Sw
iss
roll
Ch
oco
late
mu
ffin
s
Co
con
ut
Wal
nu
t
Iced
Mad
eira
Co
ffe
e
Vic
tori
a
Bat
ten
ber
g
An
gel
Bak
ewel
l
Alm
on
d
Lem
on
Ca
rro
t
Mad
eir
a
Gin
ger
Fru
ite
d M
ade
ira
Blu
eber
ry m
uff
ins
Lem
on
Sw
iss
roll
Fru
it
Fru
it S
wis
s ro
ll
Gen
oa
Energy(kcal/100g)
Different cakes
Energy in cakes
Cupcakes / fairy cakes
30 40 50
Cupcakes / fairy cakes
375 400 425 450 475 500
Energy (kcal/100g)
Sugars (g/100g)
• Fat: Major calorie contributor
• Easy to reformulate (2.5 X calorie/g)
• ↓ Sat fat → ↓ LDL cholesterol
• Incremental targets, aim ↓ 20%
Calorie / Fat
This will ↓calorie intake by >100 Kcal/person/d
Obesity plan by AoS for UK 2015
1. Incremental reduction
3. 20% sugar levy (+reformulation)
─ soft drinks
Sugar 50% ↓
Fat (Sat) 20% ↓
2. Only healthy foods promoted/advertised
↓100 Kcal/person/d
↓100 Kcal/person/d
↓ 100 Kcal/person/d
4. Public sector strict guidelines
5. Uniform colour-coded labelling
UK Obesity Plan 2017
• Tax on sugar-sweetened drinks (opportunity to
reformulate)
• 20% voluntary sugar reformulation by 2020 (PHE)
• Targets to be set for calorie reduction (fat)
• No restrictions on marketing or promotion
UK Sugar levy 2018
>8 g/100 ml (8% sugar) tax 24p /L
5-8 g/100 ml (5-8% sugar) tax 18p /L
<5 g/100 ml (<5% sugar) No tax
Nearly all branded & supermarket own label have
reformulated <5 g/100 ml
Only Coca Cola/Pepsi have kept full sugar drinks
Fantastic for Public Health
Very little
cost
Food industry slowly reduce salt, sugar & fat
- No rejection by public
No need to
change diet
Reformulation of unhealthy foode.g. processed, fast, takeaway, restaurant food
↓ BP, obesity
& cholesterol
• Incremental taxes on unhealthy foods
• Ban all marketing of unhealthy foods
The last chance saloon
If industry does not respond