National Institute of Health Research using Official Development Assistance (ODA

He, FJ

Li, Y

MacGregor, GA

Zhang, P

The Lancet

Queen Mary Research Online

Action on Salt ChinaFeng J He,1* Puhong Zhang,2,3* Yuan Li,2,3 Graham A MacGregor11 Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, UK2 The George Institute for Global Health at Peking University Health Science Center, China.3 Faculty of Medicine, University of New South Wales, Australia*Joint first authorWord count: 898Correspondence to:Dr. Feng J HeWolfson Institute of Preventive Medicine, Barts and The London School of Medicine & Dentistry,Queen Mary University of London,Charterhouse Square,London EC1M 6BQ.Tel: 44 (0)20 7882 6266Fax: 44 (0)20 7882 6270 E-mail: f.he@qmul.ac.uk (​mailto:f.he@qmul.ac.uk​)Professor Puhong ZhangThe George Institute for Global Health at Peking University Health Science Center, Level 18, Tower B, Horizon Tower, No. 6 Zhichun Rd,Haidian District | Beijing, 100088 P.R. ChinaTel: +86 10 8280 0577 ext 512Fax: +8610 8280 0177E-mail: zpuhong@georgeinstitute.org.cnCardiovascular disease (CVD) is the major cause of death and disability, ≈80% of which occur in developing countries.1  Raised blood pressure (BP) from as low as 115/75 mmHg, is an important risk factor for CVD. Excessive salt consumption is the leading cause of raised BP. The current salt intake among adults in most countries is ≈10 g/d.2 The World Health Organisation (WHO) has recommended a 30% reduction by 2025 with a long-term target of <5 g/d. Many developed countries have started taking actions. Salt intake has been reduced in Finland and the UK, accompanied by falls in population BP and CVD mortality.3 Developing countries are, however, lagging behind. As the largest developing country, China has ≈20% of the world population. Salt intake in China is high with an average being 12-14 g/d. ADDIN EN.CITE 4 Over 244 million Chinese adults had hypertension and another 435 million had pre-hypertension (120-139/80-89 mmHg), and raised BP contributed to ≈2.33 million CVD deaths in 2012. ADDIN EN.CITE , These figures are increasing rapidly because of the fast economic and epidemiological transition. Over 50% of the hypertensive individuals are not aware of their condition.5 A strategy such as salt reduction to lower population BP is of paramount importance. In China and many other developing countries, most of the salt is added by the consumers during cooking or in sauces. It is extremely challenging to reduce salt intake in such settings due to the difficulty in changing individuals’ dietary behaviour. Various approaches have been developed with encouraging results in local/regional studies. Replacing usual salt with a potassium-enriched salt which has less sodium and increased potassium, has been shown, in randomised trials, to reduce BP and CVD mortality.7 Currently, most salt substitutes on the Chinese market contain 25-30% potassium chloride and 70-75% sodium chloride. A strategy to gradually increase potassium and reduce sodium content is needed.Although promising, salt substitution alone will not be sufficient to reduce the Chinese population’s salt intake to the WHO recommended level. It is vital that individuals reduce the amount of salt used. The question is how to encourage the public to achieve this. A study in northern China demonstrated that children could play a key role.8 In a cluster randomised trial, primary schoolchildren were taught during their usual heath education lessons about the harmful effects of salt and how to reduce salt intake. Children then instructed their family to reduce salt. After one school term (≈3.5 months),  salt intake as measured by 24-h urinary sodium  decreased by 1.9 g/d in children and 2.9 g/d in adults.8 This programme, if implemented and sustained across China, would prevent ≈200,000 CVD deaths/year, resulting in major cost-savings. ADDIN EN.CITE ,There has also been a rapid increase in the consumption of processed food due to urbanisation in China. The food industry plays an increasingly important role. The UK has pioneered a successful salt reduction model in settings where most of the salt is from processed food.  By setting incremental lower salt targets for 85 categories of food which provides a level playing field for all food manufacturers, the salt content in many foods has decreased by 20-50%.10 Many countries are following the UK’s model. In 2016, the US Food and Drug Administration proposed salt targets for ≈150 food categories. Several countries, e.g. South Africa, have set mandatory targets.  Legislation is the preferable approach as it is more effective than voluntary one, however, the long and complicated legislative process in many countries including China, may delay action. It is best to start with voluntary salt-reduction targets whilst regulation/legislation is enacted.Various regional multifaceted salt reduction programmes such as SMASH (Shandong-Ministry of Health Action on Salt Reduction and Hypertension), have been carried out in China. Evaluation of these programmes will be vital for its application to other parts of the country. The Chinese central government has included salt reduction as one of the key components of China’s health development agenda, e.g. “Healthy China 2030”. The policy set a good starting point, but needs a structured coherent detailed plan.Recently an action group, i.e. Action on Salt China (ASC), has been set up. ASC is an NIHR (National Institute for Health and Research) funded Unit, led by Queen Mary University of London, The George Institute China, Chinese Center for Disease Control and Prevention (China CDC), National Health Education Center and National Food Safety Risk Assessment Center, in partnership with provincial health and education authorities. ASC aims to develop and implement a comprehensive, effective and sustainable national salt reduction programme to help achieve the WHO’s recommended salt intake in China.ASC has developed a strategic plan with a series of coherent programmes including 1) health education to increase salt awareness; 2) community, school and family-based education programmes to encourage individuals to reduce salt used at home; 3) reducing salt in restaurant meals; and 4) reformulation by setting salt targets for processed food, improving nutritional labelling, and providing tools to help consumers to choose foods with less salt. Many of the ASC’s activities are intended to have an impact at policy level to ensure sustainability. Salt reduction has already received strong support from the Chinese central and provincial government, non-governmental organisations, academia, food industries, health professionals, and the public. ASC calls for continuing support and participation from all provinces across China. Sustained and well-orchestrated efforts will be needed to successfully reduce salt intake, which will not only benefit the Chinese population, preventing millions of unnecessary CVDs, but also contribute to global health development. Declaration of interestsFJH is a member of Consensus Action on Salt & Health (CASH) and World Action on Salt & Health (WASH). Both CASH and WASH are non-profit charitable organisations and FJH does not receive any financial support from CASH or WASH. GAM is Chairman of Blood Pressure UK (BPUK), Chairman of CASH and Chairman of WASH. BPUK, CASH and WASH are non-profit charitable organisations. GAM does not receive any financial support from any of these organisations.Acknowledgement: ASC research is commissioned by the National Institute of Health Research using Official Development Assistance (ODA) funding. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. References1.	Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371: 1513-8.2.	Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3: e003733.3.	He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open 2014; 4: e004549.4.	Shao S, Hua Y, Yang Y, et al. Salt reduction in China: a state-of-the-art review. Risk Manag Healthc Policy 2017; 10: 17-28.5.	Wang Z, Chen Z, Zhang L, et al. Status of Hypertension in China: Results from the China Hypertension Survey, 2012-2015. Circulation 2018.6.	He J, Gu D, Chen J, et al. Premature deaths attributable to blood pressure in China: a prospective cohort study. Lancet 2009; 374: 1765-72.7.	Chang HY, Hu YW, Yue CS, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr 2006; 83: 1289-96.8.	He FJ, Wu Y, Feng XX, et al. School based education programme to reduce salt intake in children and their families (School-EduSalt): cluster randomised controlled trial. BMJ 2015; 350: h770.9.	Li X, Jan S, Yan LL, et al. Cost and cost-effectiveness of a school-based education program to reduce salt intake in children and their families in China. PLoS One 2017; 12: e0183033.10.	He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014; 28: 345-52.2.	Powles J, Fahimi S, Micha R, et al. Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open 2013; 3: e003733.3.	He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open 2014; 4: e004549.4.	Shao S, Hua Y, Yang Y, et al. Salt reduction in China: a state-of-the-art review. Risk Manag Healthc Policy 2017; 10: 17-28.5.	Wang Z, Chen Z, Zhang L, et al. Status of Hypertension in China: Results from the China Hypertension Survey, 2012-2015. Circulation 2018.6.	He J, Gu D, Chen J, et al. Premature deaths attributable to blood pressure in China: a prospective cohort study. Lancet 2009; 374: 1765-72.7.	Chang HY, Hu YW, Yue CS, et al. Effect of potassium-enriched salt on cardiovascular mortality and medical expenses of elderly men. Am J Clin Nutr 2006; 83: 1289-96.8.	He FJ, Wu Y, Feng XX, et al. School based education programme to reduce salt intake in children and their families (School-EduSalt): cluster randomised controlled trial. BMJ 2015; 350: h770.9.	Li X, Jan S, Yan LL, et al. Cost and cost-effectiveness of a school-based education program to reduce salt intake in children and their families in China. PLoS One 2017; 12: e0183033.10.	He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2014; 28: 345-52.PAGE  2

Action on Salt China

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Action on Salt China

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