Health Responsibility Deal on salt intake and population health Dr. - - PowerPoint PPT Presentation

Quantifying the impact of the Public Health Responsibility Deal on salt intake and population health

• Dr. Anthony Laverty

Primary Care & Public Health Imperial College London

21st September 2018

Salt intake

Salt intake above recommended levels linked to both CVD and Gastric Cancer, and attributed to 1.65 CVD million deaths worldwide in 2010 (Mozafarian 2014, D'Elia 2012) The WHO has recommended reducing population levels of salt intake as a “best buy” in terms of population health, although it has not been specific on how best to achieve this.

A brief history of salt policy in England

1994 – Committee on Medical Aspects of Food recommends 6 grams per day level of salt intake. Rejected by Department of Health in 1996 2000 – establishment of FSA, including remit for nutritional intakes (i.e. not just food safety) 2001 – Chief Medical Officer endorses 6g per day limit 2003 - Scientific Advisory Committee on Nutrition (SACN) publishes “Salt and Health” report and FSA formally adopts salt reduction strategy 2005 – FSA publishes targets for 85 categories of food, developed in conjunction with CASH

England Salt reduction strategy 2003 - 2010

A three pronged strategy: Reformulation

Public Health Responsibility Deal

• A 2011 initiative by new coalition government
• Involved five networks of food, alcohol, physical activity, health at work, or

behaviour change.

• Argued that voluntary approach allows practical actions to be agreed upon

more quickly and with less cost than legislation

• Also represented one of many public-private partnerships developed to

improve health and nutrition worldwide. Driven in part by being seen as middle ground between self regulation and government legislation

FSA strategy vs. Responsibility Deal

FSA strategy 2003 - 2010 RD strategy 2011 - 2017 Targets Specific targets by food category. Approx 10 - 20% reductions. Developed by FSA in conjunction with CASH Original commitment to FSA targets until 2012, then set by food industry Activities Awareness campaigns, food labelling, reformulation Varied pledges including training chefs to use less in cooking, displaying salt content on menus amd reformulation Monitoring Establishment of national salt intake data collections analysed by FSA with public reports A plenary group of senior representatives from the business community, NGOs, public health organisations and local government oversaw the RD, with monitoring by the Department of Health. For some pledges, partners were be asked to report using pre-defined quantitative measures, while for others they were asked for a narrative update. Involvement Voluntary involvement and targets were underpinned by direct pressure from the FSA, non-governmental organisations (NGOs) and Government Ministers threatening further regulation Voluntary

Overarching question

• What has the impact of the Responsibility Deal been on salt intakes in

England?

• And what are the impacts of this on CVD and gastric cancer incidence,

mortality and economic costs in England from 2011-2025?

Methods

• 1. Interrupted time series analyses of trends in population salt intake pre and

post Responsibility Deal

• 2. IMPACTNCD microsimulation modelling of health, equity, and economic

impacts

Salt Data

• All salt intake data used here came from 24-hour urine collections

Dates of 24-hour urine collection N included in analyses National Diet and Nutrition Survey 2000/1 July 2000 to June 2001 1,029 England 2006 sodium survey October 2005 to July 2006 445 UK 2008 sodium survey January to May 2008 571 England 2011 sodium survey July to December 2011 499 England 2014 sodium survey May to September 2014 622 National Diet and Nutrition Survey Rolling Programme (sensitivity analyses only) 2008 January to December 2008 75 2009 January to December 2009 96 2010 January to December 2010 101 2011 January to December 2011 154 2012 January to December 2012 153 2013 January to June 2013 88

ITS

• Adjusted for age group of participants
• Stratify by sex
• Gives – what was trend in intakes before RD, what was trend after

RD, and are these different to each other?

IMPACTNCD

• Developed by colleagues at University of Liverpool
• Creates a synthetic population to allow simulation of changing risk factors on

disease outcomes and uses probabilistic sensitivity analyses to estimate uncertainty

• Population data based on ONS statistics and other risk factors from Health

Survey for England

• Associations of salt intake with Gastric Cancer & CVD come from meta-

analyses of longitudinal studies

• Time lags between exposure and outcomes – CVD 5 year median lag (range

1 – 10 years), Gastric Cancer 8 year median (range 1 – 10 years)

Scenarios

Two main scenarios (plus sensitivity analysis) Divided estimates into 2011 – 2018, and 2019 - 2025

Results

Pre- and post-Responsibility Deal trends of salt intake in England 2000/01 to 2014

Estimates of salt intake pre and post RD

Men Coefficient 95% CI p-value Intercept 11.07 10.43 11.70 <0.001 Change in salt intake per year 2000 - 2010

• 0.20
• 0.29
• 0.12

<0.001 Post-Responsibility Deal annual trend

• 0.11
• 0.15
• 0.06

<0.001 Women Intercept 8.75 8.30 9.19 <0.001 Change in salt intake per year 2000 - 2010

• 0.12
• 0.18
• 0.06

<0.001 Post-Responsibility Deal annual trend

• 0.07
• 0.10
• 0.04

<0.001

Estimates of CVD and Gastric cancer

Disease Period of exposure Absolute number of additional cases (IQR) Absolute number of additional deaths (IQR) CVD 2011-2018 9,900 (IQR: 6,700 to 13,000) 710 (IQR: -510 to 2,300 2019-2025 26,000 (20,000 to 31,000) 5,500 (2,800 to 8,500) 2011-2025 35,000 (29,000 to 42,000) 6,400 (3,200 to 9,400) GCa 2011-2018 1,500 (510 to 2,300) 610 (-310 to 1,500) 2019-2025 3,800 (2,200 to 5,300) 1,900 (790 to 3,100) 2011-2025 5,300 (3,400 to 7,200) 2,500 (920 to 3,900)

Estimated health care costs of £110 million, plus £47million in productivity costs (2011 – 2018) Plus further health care costs £650 million and £320 million in productivity (2019 – 2025)

Impacts across deprivation quintiles

Disease QIMD (5 = most deprived) Absolute number of additional cases (IQR) Rate per 100,000 person- years (IQR) Rate per 100,000 new CVD cases 2011 – 2018 CVD 1 1,600 (-200 to 3,600) 3.0 (-0.38 to 6.7) 1,200 (-150 to 2,700) 2 1,900 (200 to 4,100) 3.6 (0.38 to 7.5) 1,300 (130 to 2,700) 3 1,900 (100 to 4,100) 3.6 (0.19 to 7.5) 1,300 (65 to 2,800) 4 2,000 (2800 to 4,100) 3.9 (0.52 to 7.7) 1,500 (200 to 2,900) 5 2,000 (200 to 4,000) 4.1 (0.4 to 7.8) 1,500 (150 to 2,800) GCa 1 200 (-310 to 820) 0.37 (-0.75 to 1.5) 910 (-4,400 to 5,400) 2 310 (-310 to 920) 0.56 (-0.56 to 1.7) 1,000 (-4,000 to 6,100) 3 310 (-310 to 820) 0.57 (-0.56 to 1.5) 420 (-3,500 to 5,900) 4 410 (-200 to 940) 0.76 (-0.39 to 1.8) 1,300 (-4,100 to 6,800) 5 310 (-200 to 920) 0.59 (-0.39 to 1.7) 1,200 (-4,200 to 7,100)

Results for 2019 – 2015 not shown here but similar gradients

Key findings

• Salt intake coming down in England, but this has slowed
• But implementation of new policy linked with slow down in this
• This associated with approximately 10,000 additional cases of CVD and 1,500

cases of GCa to date (2011-2018), with an additional 26,000 cases of CVD and 3,800 cases of GCa projected if this policy is continued until 2025.

• Health impacts were larger among more deprived populations
• Associated healthcare and productivity costs exceeded £1 billion between

2011 and 2025.

Potential limitations

• Small sample sizes in some years
• Lack of 24 hour urine data on participants aged 65+ years
• Lack of socio-economic circumstance information in salt data
• Assumptions

Why does this matter?

From Trieu et al (2015) Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target

Responsibility Deal always controversial

• Many health groups including FPH and BMA pulled out of deal.
• BMA: “In particular, there has often been an over-reliance in national policymaking on

‘nudge’ measures, personal responsibility and voluntary industry action, as these are generally less intrusive. This is typified in England by the introduction of the ‘Public Health Responsibility Deal’ in 2011, which relied on a series of voluntary pledges with industry across a range of areas, including alcohol and diet”

Conclusion

• The Public Health Responsibility Deal was

linked to a slowing in the decline of salt intakes in England

• This in turn linked to excess CVD, Gastric

cancer and social costs

• Without robust independent target setting and

monitoring, it remains questionable whether such schemes will be effective

• PHE consulting on salt reduction policy at the

end of this year

Thanks for listening

• And thanks to:

– Evi Seferidi, Eszter Vamos & Chris Millet at Imperial – Christopher Kypridemos; Jonathan Pearson-Stuttard, Simon Capewell & Martin O’Flaherty at the University of Liverpool – Modi Mwatsama at the UK Health Forum – Paul Cairney at the University of Stirling

• Funding: UK Prevention Research Partnership. UKPRP Consortium

Development Grant. UKPRP_CO1_105. QUEST: QUantifying Equitable Solutions To prevent Non-Communicable Diseases.

• Questions?