Salt reduction in the UK

1. Working with other sectors: tackling NCDs through a multisectoral response – salt reduction in the UKNick Banatvala

2. Salt reduction in the UK 2003: UK Scientific Advisory Committee on Nutrition published Salt and Health • Levels gradually increased to 9.5g per day in 2002 • Evidence for link between salt intake and hypertension stronger than ever before • Approximately 75% of the salt consumed in developed countries is found in processed foods such as bread, breakfast cereals, ready meals, cheese and sauces • Product reformulation is an important way in which to reduce population salt intake • Recommended that work should be undertaken to reduce salt intake • A reduction in intake by just 1g/person/day in the UK was save 6,000 lives every year

3. Principles of UK salt reduction strategy

4. Salt reduction in the UK • 2003: HMG accepted SACN’s recommendation – towards 6g salt/day for adults • 2003: Public Health minister initiated a series of meetings with individual organizations and stakeholder groups to discuss salt reduction • 2006: Voluntary salt reduction targets published following public consultation, with commitment to review targets in 2008 • Three strands • Public health campaign • Collaboration with industry of reformulation • Development of single front-of-pack nutrition labeling scheme • 2009: Further salt reduction targets published

5. Voluntary vs prescriptive regulation Prescriptive regulation on reformulation would have: • been overly complex due to the wide range of foods and additives which contain sodium, • potentially delayed Government intervention whilst regulations were drafted and approved, • placed significant burdens on industry • required a costly enforcement regime. • Been especially difficult as food law is an EU competence • Prevented the FSA advocate for the highest reductions possible instead of setting less ambitious targets which would have been the case if these were set in legislation • Prevented review on a more regular basis, taking into account technological advances and developing targets based on what leading companies have achieved.

6. Mechanism • Voluntary salt reduction targets for a range of processed foods were established in collaboration with the food industry. • Targets published in 2006 and following a 2008 review, more challenging targets set across more than 80 categories of food. • Take up of the scheme achieved through an effective partnership with industry, involving businesses in the development of the targets, working to understand and address technical barriers and helping participant businesses gain a competitive advantage by acting responsibly. • Competitive advantage has been facilitated through government promotion of positive behaviors; in the case of the Salt Reduction Strategy this has included the publication of the salt commitment table, press and ministerial statements highlighting successful/progressive businesses and brands. • Government to bring stakeholders together (including media), establish targets and parameters for review, to monitor progress, provide technical expertise, and promote and utilize research.

7. Progress made… • Salt content of processed food has progressively reduced by between 10-50% depending on the category of food • The salt content of packaged bread, the biggest contributor of salt to the UK diet, has reduced by 20% from 1.23g/100g to 0.98g/100g (for pre-packed, sliced bread around a third) • Reductions of about 44% have been achieved in branded breakfast cereals • Reductions of between 16% and 50% have been achieved in some top-selling cakes and biscuits between 2006 and 2007 • There have also been reductions in processed cheese products, including a range of soft white cheeses with 50% less salt for the UK market, a 32% reduction in some retail standard cheese slices, and 21% in the equivalent reduced-fat cheese slices. • Earlier work led by the Food and Drink Federation (Project Neptune) produced reductions of about 30% in cooking and pasta sauces and 25% in soups by a range of the largest manufacturers.

8. Progress made… • 81 companies are committed to reducing salt in their products • The target based approach has been successful with, for example, the number of bread products meeting 2012 targets increasing from 31% to 71% • Many products have front of pack nutrition information displayed, and many companies are now committed to including both traffic light colours and percentage guidelines daily amounts • The UK has successfully achieved a reduction in average salt intake from 9.5g/person/day in 2002 to 8.1g/person/day in 2012. • (Urinary sodium excretion, for adults aged 19 to 64 years was 8.1g per day, mean estimated intake for men = 9.3g per day, women 6.8g per day.)

9. 9.5g per day to 8.1g per day

10. Reducing salt intakes through voluntary reformulation and increasing public awareness has been a highly cost effective policy option • 10% reduction in salt intake achieved to date has • saved the economy £1.5 billion • prevented around 8,500 premature deaths annually. • Approximately £18.6 million has been spent on the public awareness campaign to date which supports the reformulation part of the programme.

11. Risks • Designing a scheme which was overly onerous and thereby causing businesses to disengage • Establishing targets which are easily achievable but fail to deliver the policy objectives • If businesses perceive that the policy is no longer on the Government’s agenda • Potential for responsible businesses to lose custom to those who do not take up the scheme, including companies exporting to the UK.

12. Lessons learnt from the voluntary approach • Can work where there is consensus as to the validity of the government’s policy objectives. • Should be supported by an equivalent evidence base to a regulatory measure with sufficient research to support the policy and its cost effectiveness. • A mechanism designed in partnership is most likely to produce targets which are both effective and realistic. • Useful to establish a broad base of support in principle and work with these early adopters to develop targets which industry can buy into. • An effective working relationship with industry is vital and will involve officials meeting regularly both with trade associations and individual companies and also highlighting and promoting the initiative regularly at trade conferences. It also requires ongoing political support. • Policy makers should accept that businesses will face barriers they have not considered and that any initiative will need to have the flexibility to adapt to these challenges. Drawing out these challenges is most effective early in the development stage. • In designing the scheme policy makers should understand the political, commercial and technical challenges facing businesses and be prepared to adapt appropriately. There will be businesses who believe targets go too far or cannot be achieved; however, effective engagement should inform targets which are challenging but achievable and a staged approach might usefully be considered.

13. Lessons learnt from the voluntary approach • Government should be aware that even in a voluntary scheme businesses may incur significant costs in participating. As a result there should be an opportunity for businesses to develop competitive advantage by signing up to the scheme particularly in the current economic climate. Early consideration of ‘reward’ for industry co-operation is advised; openly praise early adopters and those businesses making significant progress and recognise the costs they have incurred in complying. • Challenge inertia but accept the difficulties faced by some businesses and work with them to identify solutions. • Keep the initiative ‘live’ by including references in speeches by ministers and high level officials • Engage policy makers outside the UK where appropriate.

14. Presentation name / Author

15. Working intersectorally Work sites Education Food industry Taxation Business Media Agriculture Legislation Third sector Research Health services

16. What is Health in All Policies (HiAP) approach? • Horizontal, complementary policy related strategy • The core of HiAP is to examine determinants of health -> are mainly controlled by policies of sectors other than health • Addresses policies in the context of policy-making at all levels of governance (global, European, national, regional and local levels) • The ultimate aim of HiAP is to improve evidence informed policy-making Ståhl et al. (eds). Health in All Policies – Prospects and potentials, 2006

17. alcohol policy tax on alcohol alcohol consumption health and social harms Focus on policies • Key concern: policies • The broad economic, social, environmental and cultural health determinants are the bridge between policies and health outcomes • For example, alcohol policy (tax) influences the price of alcohol that has an effect on alcohol consumption that (alcohol abuse) in turn has an effect on harms, both health and social • Less concerned with single programmes and projects

18. Broad determinants of health • Social, economic, structural, environmental, cultural • Present everywhere in the society • Often beyond the control of individuals • Same determinants are linked with many major public health problems (nutrition, physical activity, tobacco, alcohol, psychosocial situation, stress) • Mostly a responsibility of other government sectors • Impossible to target effectively through sectorial health policies alone

19. Intersectoral mechanisms/tools for implementing HiAP • Formal consultations on e.g. legislation • Horizontal public health committees • Ad hoc committees on specific initiatives • Cross-sectorial programmes • Public health reporting (with co-operation of other sectors) • Formal communication between sectors (e.g. bilateral meetings of Permanent Secretaries) • Informal contacts at desk level • EU co-ordination • Health impact assessment Stahl T (2009) Is health recognized in the EU's policy process? An analysis of the European Commission's impact assessments. The European Journal of Public Health 2009; doi: 10.1093/eurpub/ckp082