South Africa has been a trailblazer on the continent in the global battle to reduce salt intake through food. But three years after the bold food policy was first introduced in South Africa – and less than a year until it finally becomes law – the country has still not set up programmes to monitor how effective the legislation will be.
Ideally, baseline studies measuring salt intake across the country should be done by now. When the legislation kicks in, a follow-up study can then produce evidence to back up the law. These are still not in place.
Leading the way in 2012, South Africa developed legislation that limits the levels of salt in processed foods. Only a handful of countries in the rest of the world have opted for mandatory legislation. They are Portugal, Belgium, Finland, Greece, Argentina and Paraguay. This is presumably because of difficulties in enforcing such a food policy.
Too much passing the salt
On average, South Africans consume between 7.8 and 9.5g of salt per day, hidden in foods and added at the table. This is equivalent to one and a half teaspoons and far exceeds the World Health Organisation’s 5g a day (one teaspoon) recommendation. The World Health Organisation estimates that the global mean intake is around 10g of salt per person daily.
This high salt diet along with rapid urbanisation, high fat intakes, exposure to chronic stress, tobacco and alcohol abuse as well as low physical activity levels, has resulted in an alarming increase in non-communicable diseases, particularly hypertension.
A century ago it was difficult to find a hypertensive patient in Africa. Today, South Africa is the hypertension centre among low and middle income countries, with close to 80% of those aged 50 years and older suffering from the disease.
Globally, non-communicable diseases, including cardiovascular disease, are responsible for two thirds, or 36 million deaths annually. Low and middle income countries carry 80% of this burden. Ischaemic heart disease and strokes are the top two killers.
Less salt will save lives and cut costs
South Africa’s salt-limiting legislation was a result of international political pressure and local research supporting a salt reduction strategy.
The legislation means that bread, as the biggest contributor to overall salt intake, will have to be manufactured with less salt. It will also see the sodium content reduced in margarine, soups, stock cubes and a range of other processed foods including meat products, biscuits and crackers, instant noodles and sauces.
Several sectors of the food industry opposed the draft legislation during the public consultation process. They argued that it would create technological difficulties, particularly in the bread baking process. But research showed the proposed levels for 2016 of 400mg sodium for each 100g bread could be achieved, with no adverse effects on taste, appearance or consumer acceptance.
The reduction will mean that there will be less than a quarter teaspoon of salt in every three slices of bread. Along with the salt cuts in the other products, the salt intake in South Africa should decrease by 0.85g per person a day. This may seem insignificant but could result in a substantial difference to the population’s health.
From a disease perspective, it is estimated that the cut will lead to a 10% drop – or 7000 fewer deaths from heart attacks – and 4000 less non-fatal strokes each year. South Africa is estimated to realise a health-care saving of R300m each year for non-fatal strokes alone.
South Africa considered a trailblazer
The country’s legislation is one of the salt-reduction strategies considered by the World Health Organisation (WHO) as a “best-buy” in the overall approach to the prevention of cardiovascular disease.
In 2011, influential leaders at a United Nations meeting on non-communicable diseases reached consensus that salt reduction was one of the five global priorities to prevent and treat these diseases.
At that time, 32 countries, mostly from Europe, had salt reduction initiatives in place. These included food reformulation, consumer awareness initiatives and food labelling.
The number of countries with salt initiatives have since doubled from 32 to 75. Only two African countries – South Africa and Mauritius – are on the list, of which only South Africa has legislated.
The UK is the most successful example of a country with voluntary salt targets. The targets were first developed by the Food Standards Agency for processed foods in 2003, along with a social marketing campaign “Sid the Slug”. The marketing message was based on the fact that salt kills slugs and can harm humans too.
By 2010, most processed foods cut salt by 20% to 30% from its 2003 level. As a result, salt intake has been reduced by 1g per person, saving 8000 lives annually. Parallel reductions in blood pressure and stroke mortality have been reported.
Jury still out on legislation vs voluntary
But it remains to be seen whether South Africa’s legislation will be more effective than voluntary target-setting in the UK. There are several possible pitfalls that may railroad its success.
Firstly, there is a concern that people may compensate by simply adding more salt to foods. To mitigate this the National Department of Health pledged R5m in 2014 for a healthy food choices consumer campaign “Salt Watch” to increase awareness of the link between salt and blood pressure.
Secondly, implementation of the legislation will need to be monitored. Salt intake data will need to be collected within existing national health surveys. If government funding does not pan out, as is the concern, other funding sources will need to be found.
South Africa is one of six low to middle income countries taking part in a World Health Organisation study on global ageing and adult health where a 24-hour analysis of the levels of sodium excreted in urine will be analysed. The limitation of the study is that it only looks at people over the age of 50. This means that salt intake in younger people will still not be measured.
The world will be watching South Africa. But monitoring the impacts of its strategy on food and the health will require an integrated approach by government, academia, and non-governmental agencies, spearheaded by a salt reduction crusader.