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

Salt, Sugar & Fat

Major Underlying Factors Causing Death - Worldwide

GBD 2013 Risk Factors Collaborators. Lancet 2015;385:117

Number of Deaths in thousands

0 2,000 4,000 6,000 8,000 10,000 12,000

Sexual abuse and violence

Low bone mineral density

Occupational risks

Other environmental risks

Unsafe water, sanitation, and handwashing

Unsafe sex

Child and maternal malnutrition

Low GFR

Low physical activity

High total cholesterol

Alcohol and drug use

High fasting plasma glucose

High BMI

Air pollution

Tobacco smoke

High systolic BP

Dietary risks

0 2,000 4,000 6,000 8,000 10,000 12,000

Sexual abuse and violence

Low bone mineral density

Occupational risks

Other environmental risks

Unsafe water, sanitation, and handwashing

Unsafe sex

Child and maternal malnutrition

Low GFR

Low physical activity

High total cholesterol

Alcohol and drug use

High fasting plasma glucose

High BMI

Air pollution

Tobacco smoke

High systolic BP

Dietary risks

Unhealthy diet

High systolic BP

High BMI

High plasma glucose

High cholesterol

Processed foods and soft drinks

Fat (saturated)Sugar

Calorie

Dental

caries

Cholesterol Blood PressureObesity

Type 2

Diabetes

Cancer

Salt

Heart disease

Stroke

Systolic BP & Stroke Deaths

Systolic BP (mmHg)

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

120 125 135 148 168

2

4

8

16

32

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

Strategy

Reduction in

population BP

Better control of

raised BP

Massive Reduction in

Strokes, Heart Failure, Heart

attacks

BP – 2nd biggest cause of death in the world

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)

www.actiononsalt.org.uk

Table/Cooking (15%)

Natural (5%)

Food industry (80%)

0.9

0.5

4.6

40% reduction

No reduction

40% reduction

Salt intake Reduction needed

9.5

1.4

0.5

7.6

6.0

Source g/d

Target intakeg/d

Total

Fantastic for Public Health

Very little

cost

Food industry slowly reduce

- No rejection by public

No need to

change diet

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

↓ BP

The voluntary ‘carrot and stick’

approach

food industry

www.actiononsalt.org.uk

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

1.6

Impact of incremental targets

on salt in bread

He et al. JHH 2014;28:345

Target(g/100g)

1.1 20101.0 20120.9 2017

***

***

***

***

7

8

9

10

*

50

100

150

200

250

126

128

130

132

70

72

74

76

Deaths

per

100,000

per year

Blood

pressure

(mmHg)

Salt intake

(g/d)(from 24h UNa)

IHD

Stroke

2003 2006 2008 2011

Salt Intake, BP and CVD Mortality in England 2003─2011

He et al. BMJ Open 2014;

4:e004549

* P<0.05

*** P<0.001

≈18,000

(9,000 fatal)

CVDs

prevented

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

≈ £1.5 billion

healthcare

savings

per year

Countries with salt targets

Argentina

Belgium

Bulgaria

Chile

Greece

Hungary

Netherlands

Paraguay

Portugal

South Africa

(29/30 companies preferred regulation)

RegulatedVoluntaryAustralia

Brazil

Canada

Ireland

Italy

Kuwait

New Zealand

Norway

Poland

Turkey

UK

USA

Why are we getting so fat?

11 bananas or 18 oranges

or half a marathon

A Big Mac, large

chips and coca cola

Food/soft drink industry

Calorie-dense

Cheap

Profitable

Transient

satiation/

fullness

Calorie intake ↑

Obesity/type 2 diabetes ↑

“Brilliant” marketing

Any time

Everywhere

Eat more

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)

x11

x9

x7

x6

x4

x6

x5

x4

Sugar: Spinning a web of influence

• Liquid: easy to reduce

• Solid: ↓portion size, polyols, insoluble fibre

• Incremental targets, aim 50% reduction

• Artificial sweeteners?: Need to ↓sweetness

Incremental sugar targets like salt

This will ↓calorie intake by >100 Kcal/person/d

Bat

ten

be

rg

Ge

no

a

Re

d v

elv

et

Lem

on

Sw

iss

roll

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cak

e b

ar

Gin

ger

Cu

pca

ke/f

airy

cak

es

Fru

it S

wis

s ro

ll

Co

con

ut

Ice

d M

ade

ira

Bro

wn

ies

Fru

it

Ch

oco

late

Sw

iss

roll

Vic

tori

a

Co

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e a

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wal

nu

t

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ite

d M

ade

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Bak

ew

ell

Lem

on

Car

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Wh

ite

ch

oco

late

Alm

on

d

An

gel

Ch

oco

late

Co

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e

Wal

nu

t

Ch

oco

late

mu

ffin

s

Mad

eir

a

Pla

in w

ith

ch

oco

late

Blu

eb

err

y m

uff

ins

Sugars(g/100g)

Different cakes

Sugar in cakes

Pla

in w

ith

ch

oco

late

Ch

oco

late

cak

e b

ar

Cu

pca

ke/f

air

y ca

kes

Co

ffe

e an

d w

aln

ut

Red

vel

vet

Ch

oco

late

Bro

wn

ies

Wh

ite

ch

oco

late

Ch

oco

late

Sw

iss

roll

Ch

oco

late

mu

ffin

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Co

con

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Wal

nu

t

Iced

Mad

eira

Co

ffe

e

Vic

tori

a

Bat

ten

ber

g

An

gel

Bak

ewel

l

Alm

on

d

Lem

on

Ca

rro

t

Mad

eir

a

Gin

ger

Fru

ite

d M

ade

ira

Blu

eber

ry m

uff

ins

Lem

on

Sw

iss

roll

Fru

it

Fru

it S

wis

s ro

ll

Gen

oa

Energy(kcal/100g)

Different cakes

Energy in cakes

Cupcakes / fairy cakes

30 40 50

Cupcakes / fairy cakes

375 400 425 450 475 500

Energy (kcal/100g)

Sugars (g/100g)

• Fat: Major calorie contributor

• Easy to reformulate (2.5 X calorie/g)

• ↓ Sat fat → ↓ LDL cholesterol

• Incremental targets, aim ↓ 20%

Calorie / Fat

This will ↓calorie intake by >100 Kcal/person/d

Obesity plan by AoS for UK 2015

1. Incremental reduction

3. 20% sugar levy (+reformulation)

─ soft drinks

Sugar 50% ↓

Fat (Sat) 20% ↓

2. Only healthy foods promoted/advertised

↓100 Kcal/person/d

↓100 Kcal/person/d

↓ 100 Kcal/person/d

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

Fantastic for Public Health

Very little

cost

Food industry slowly reduce salt, sugar & fat

- No rejection by public

No need to

change diet

Reformulation of unhealthy foode.g. processed, fast, takeaway, restaurant food

↓ BP, obesity

& cholesterol

• Incremental taxes on unhealthy foods

• Ban all marketing of unhealthy foods

The last chance saloon

If industry does not respond