NCD Prevention

Public Health Strategies

Hong Kong

Graham A 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

Ezzati et al. Lancet 2002:360:1347-60.

Underweight

Unsafe water, sani & hygiene

Alcohol

Physical inactivity

High BMI

Low fruit &

vegetables intake

Unsafe sex

High cholesterol

Tobacco

Raised Blood Pressure

0 1 2 3 4 5 6 7

Millions of Deaths

7 million

Developing region

Developed region

Systolic BP and Risk of Death

Systolic Blood Pressure (mmHg)

Heart Deaths 16

8

4

2

1

120 125 135 148 168

Risk

120 125 135 148 168

2

4

8

16

32

Stroke Deaths

The risk starts at systolic 115 mmHg (83% adults)

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

Johnson et al Am J Clin Nutr 2007

Obesity and Diabetes: The Twin Epidemics

One in three adults are obese

One in nine adults are diabetic

One in 30 adults are obese One in 50,000

adults are diabetic

Obesity Epidemic

11 bananas or 14

apples or 18 oranges

A Big Mac, large

chips and coca cola

Ultraprocessed fast foods

Saturated fat ↑ Sugar ↑ Salt ↑

Calorie ↑

Obesity↑ Diabetes↑ Cholesterol↑ BP↑

No feeling of fullness = Eat more

What puts up population BP?

• Salt intake

• Lack of Fruit and vegetables

• Weight

• Lack of Exercise

• (Alcohol excess)

Salt - Hong Kong

Salt intake (9–12 g/day)

Reduce salt intake

• Population BP, rise in BP with age, hypertension

• Other effects e.g. stomach cancer, stroke, LVH,

kidney disease, osteoporosis etc

from 9–12 g/day to 5 g/day

How to ↓ Salt Intake

Measure amount (24h UNa) and sources of salt

Added Cooking/Table

Sauces

Food industry Processed food

Eating out

Public health campaign

Gradual reduction in added salt

Campbell, et al. JHH. 2011

Fantastic for Public Health

Very little

cost

Food industry slowly reduce

- No rejection by public

No need to

change diet

Hidden Salt in food e.g. processed, fast, takeaway, restaurant food

↓ BP

Incremental salt targets (UK)

re-set every 2-3 years

A level playing field, i.e. same

targets for all companies. Gradual

reduction, public do not notice

The voluntary ‘carrot and stick’

approach

food industry

www.actiononsalt.org.uk

Daily Mail 2013

Salt Intake & BP in England 2003 - 2011

He et al. BMJ Open 2014; 4:e004549

NICE: http://guidance.nice.org.uk/PH25

≈18,000 (9,000 fatal) stroke/heart attacks prevented/yr

* P<0.05

*** P<0.001

Cost of salt campaign ≈£5 million per year

Healthcare savings ≈ £1.5 billion per year

http://guidance.nice.org.uk/PH25

Cost-effective Analysis UK (NICE)

Sources of salt in Hong Kong

Hong Kong

• Salt intake: ≈12 g/d (high) measured by 24h

urinary sodium

Eating out

• Set target for biggest contributors

• Monitor progress

• For voluntary policy – strong government

support & forceful NGOs essential

Processed food? • Major sources of salt

China's “Little Emperors” Become

New Health Ambassadors

School-EduSalt Results (Cluster randomised trial, 28 primary schools, ≈3.5 months)

(Intervention vs control)

Salt intake ↓ 1.9 g/d in children (27%)

↓ 2.9 g/d in adults (25%)

↓ 0.8 mmHg in children (NS)

↓ 2.3 mmHg in adults (P<0.05)

Systolic BP

He et al. BMJ 2015;350:h770

Conclusion - Salt

• ↓ Salt – very cost-effective in

preventing CVD

• Hong Kong needs

a comprehensive strategy to ↓ salt

• Many thousands of strokes & heart

attacks will be prevented

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

What is practical?

• Big food – very powerful

• Biggest industry & employer

• Strong ties to & influence on

government

• Similar to tobacco (took 50 yrs)

Voluntary reformulation

whilst legislation is enacted

What else can we do?

• Regulate/legislate/tax - salt, sugar, fat

• Ban advertising unhealthy foods &

drinks

• Restrict availability

• Reduce portion size

What can we do ?

• Salt - UK: Incremental reformulation ongoing

• Sugar - Start incremental reformulation

• Fat - Start incremental reformulation

(sat fat esp. palm oil)

• Sugar-sweetened soft drinks immediately

• Foods with added sugar (NB: No replacement. Solid

foods ↓portion size)

• Incremental targets, i.e. 5% reduction per year

(≈40% reduction within 8 yrs)

• Reduce artificial sweeteners, i.e. ↓sweetness

Incremental sugar targets

Sweetened soft drink

consumption in UK 2013

Whole population: 6 billion liters(1 L≈3 cans)

Per person : 90L/year (≈ 272 cans/year)

Per child: 135L/year(≈ 408 cans/year)

Energy intake from sweetened soft drink：

2574 billion kcal ≈ 735 million lbs

(↓ 3500 kcal↓ ≈ ↓ 1 lb)

British Soft Drinks Association, the 2014 UK Soft drinks report

Reformulation

5% reduction per year for 4

years(≈18.5%↓)

1224 billion kcal 350 million lbs

19,392 kcal 5.5 lbs

29,088 kcal 8.3 lbs

↓ Calories ↓ Weight

Population:

Per person:

Per child:

20% tax

20% tax for 4 years

5,840 kcal 1.7 lbs

↓ Calories ↓ Weight

Per person:

Adam D M Briggs, et al. BMJ, 2013. 347: p.f6189.

Tax

Reformulation Tax

Sales No reduction ↓

Cost ↓(∵less sugar) ↑

Profit ↑ ↓

↓ Calories More effective Less effective

Action Voluntary (like salt) Needs legislation

Reformulation v

Actions if food & soft drink

industry don’t act

a) Ban all marketing of unhealthy food

b) Reduce portion size & availability

c) Punitive tax on all soft drinks

Summary

1.Soft drinks – Primary target

2.Industry must act quickly to avoid

punitive measures

∴ must start immediate reformulation

a) 20% reduction in next four years(to be continued)

b) 20% reduction in sweetness