21 st September 2018 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
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 Original commitment to FSA targets until 2012, then set by 10 - 20% reductions. Developed by FSA in food industry conjunction with CASH Activities Awareness campaigns, food labelling, Varied pledges including training chefs to use less in reformulation cooking, displaying salt content on menus amd reformulation Monitoring Establishment of national salt intake data A plenary group of senior representatives from the collections analysed by FSA with public business community, NGOs, public health organisations reports 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 Voluntary underpinned by direct pressure from the FSA, non-governmental organisations (NGOs) and Government Ministers threatening further regulation
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. IMPACT NCD 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 N included in urine collection analyses July 2000 to June National Diet and Nutrition Survey 2000/1 1,029 2001 October 2005 to July England 2006 sodium survey 445 2006 UK 2008 sodium survey January to May 2008 571 England 2011 sodium survey July to December 2011 499 May to September England 2014 sodium survey 622 2014 National Diet and Nutrition Survey Rolling Programme (sensitivity analyses only) January to December 2008 75 2008 January to December 2009 96 2009 January to December 2010 101 2010 January to December 2011 154 2011 January to December 2012 153 2012 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?
IMPACT NCD • 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 Absolute number of additional Absolute number of additional Disease Period of exposure cases (IQR) 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 QIMD (5 = most Absolute number of additional Rate per 100,000 person- Rate per 100,000 new CVD Disease deprived) cases (IQR) years (IQR) 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?
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