Salt, Sugar & Fat Graham MacGregor Professor of Cardiovascular - PowerPoint PPT Presentation

Salt, Sugar & Fat 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

Major Underlying Factors Causing Death - Worldwide Dietary risks Unhealthy diet High systolic BP High systolic BP Tobacco smoke Air pollution High BMI High BMI High fasting plasma glucose High plasma glucose Alcohol and drug use High cholesterol High total cholesterol Low physical activity Sexual abuse and violence 0 2,000 4,000 6,000 8,000 10,000 12,000 Number of Deaths in thousands GBD 2013 Risk Factors Collaborators. Lancet 2015;385:117

Processed foods and soft drinks Fat (saturated) Sugar Salt Calorie Cholesterol Obesity Dental Blood Pressure caries Type 2 Diabetes Heart disease Cancer Stroke

Systolic BP & Stroke Deaths 32 16 8 Risk 4 2 120 125 135 148 168 Systolic BP (mmHg) The risk starts at systolic 115 mmHg (83% adults) MacMahon et al. Lancet 1990;335:765-74

Brain (cross section) Mid line shift due to raised pressure Cerebral haemorrhage

Atheroma in carotid artery Plaque Ulcerated Plaque Fissured Plaque with Thrombosis

Strategy BP – 2 nd biggest cause of death in the world Reduction in Better control of population BP raised BP Massive Reduction in Strokes, Heart Failure, Heart attacks

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) Salt intake Reduction Target intake needed g/d Source g/d 40% reduction Table/Cooking (15%) 1.4 0.9 No reduction Natural (5%) 0.5 0.5 40% reduction Food industry (80%) 7.6 4.6 9.5 Total 6.0 www.actiononsalt.org.uk

Hidden Salt in food e.g. processed, fast, takeaway, restaurant food Food industry slowly reduce - No rejection by public Fantastic for Public Health Very little No need to ↓ BP cost change diet

The voluntary ‘carrot and stick’ approach food industry try www.actiononsalt.org.uk

Impact of incremental targets on salt in bread 1.6 1.5 Target 1.4 (g/100g) 1.3 1.2 1.1 2010 1.1 1.0 2012 1.0 0.9 2017 0.9 0.8 0.7 0.6 He et al. JHH 2014;28:345

Salt Intake, BP and CVD Mortality in England 2003 ─ 2011 250 200 ≈18,000 Deaths per 100,000 150 *** (9,000 fatal) IHD per year CVDs 100 *** Stroke prevented 50 132 130 ≈ £1.5 billion 128 Blood healthcare *** pressure 126 (mmHg) savings 76 74 per year *** 72 NICE: http://guidance.nice.org.uk/PH25 70 10 * P<0.05 9 Salt intake *** P<0.001 (g/d) * 8 (from 24h UNa) He et al. BMJ Open 2014; 7 4:e004549 2003 2006 2008 2011

Countries with salt targets Voluntary Regulated Argentina Australia Brazil Belgium Canada Bulgaria Ireland Chile Italy Greece Kuwait Hungary New Zealand Netherlands Norway Paraguay Poland Portugal Turkey South Africa UK (29/30 companies preferred regulation) USA

Why are we getting so fat? A Big Mac, large 11 bananas or 18 oranges chips and coca cola or half a marathon

Food/soft drink industry “Brilliant” marketing Calorie-dense Transient Cheap Any time satiation/ Profitable Everywhere fullness Eat more Calorie intake ↑ Obesity/type 2 diabetes ↑

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) x6 x7 x11 x6 x5 x9 x4 x4

Sugar: Spinning a web of influence

Incremental sugar targets like salt • Liquid: easy to reduce • Solid: ↓ portion size, polyols, insoluble fibre • Incremental targets, aim 50% reduction • Artificial sweeteners?: Need to ↓ sweetness This will ↓calorie intake by >100 Kcal/person/d

(g/100g) Sugars Battenberg Genoa Red velvet Lemon Swiss roll Chocolate cake bar Ginger Cupcake/fairy cakes Sugar in cakes Fruit Swiss roll Coconut Iced Madeira Brownies Fruit Different cakes Chocolate Swiss roll Victoria Coffee and walnut Fruited Madeira Bakewell Lemon Carrot White chocolate Almond Angel Chocolate Coffee Walnut Chocolate muffins Madeira Plain with chocolate Blueberry muffins

(kcal/100g) Energy Plain with chocolate Chocolate cake bar Cupcake/fairy cakes Coffee and walnut Red velvet Chocolate Energy in cakes Brownies White chocolate Chocolate Swiss roll Chocolate muffins Coconut Different cakes Walnut Iced Madeira Coffee Victoria Battenberg Angel Bakewell Almond Lemon Carrot Madeira Ginger Fruited Madeira Blueberry muffins Lemon Swiss roll Fruit Fruit Swiss roll Genoa

Cupcakes / fairy cakes 30 40 50 Sugars (g/100g) Cupcakes / fairy cakes 375 400 425 450 475 500 Energy (kcal/100g)

Calorie / Fat • Fat : Major calorie contributor • Easy to reformulate (2.5 X calorie/g) • ↓ Sat fat → ↓ LDL cholesterol • Incremental targets, aim ↓ 20% This will ↓calorie intake by >100 Kcal/person/d

Obesity plan by AoS for UK 2015 1. Incremental reduction ↓100 Kcal/person/d Sugar 50% ↓ Fat (Sat) 20% ↓ ↓100 Kcal/person/d 2. Only healthy foods promoted/advertised ↓ 100 3. 20% sugar levy (+reformulation) Kcal/person/d ─ soft drinks 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

Reformulation of unhealthy food e.g. processed, fast, takeaway, restaurant food Food industry slowly reduce salt, sugar & fat - No rejection by public Fantastic for Public Health ↓ BP, obesity Very little No need to cost & cholesterol change diet

The last chance saloon If industry does not respond • Incremental taxes on unhealthy foods • Ban all marketing of unhealthy foods