September is heart awareness month in South Africa, an opportunity that the Heart and Stroke Foundation SA uses to intensify public awareness efforts, and a reminder to all adults to undergo screening for basic cardiovascular risk factors such as blood pressure and cholesterol levels.
Heart Awareness Month culminates in World Heart Day on September 29 and the World Heart Federation has set the theme Power Your Life.
Under the theme, the foundation unpacks several pertinent issues over each of the four weeks. Each week will focus on lifestyle choices and risk behaviours that are modifiable, such as diet and exercise, weight status and tobacco use.
Each has the power to influence our heart health independently and in synergy.
We start this campaign by emphasising excess dietary salt intake as one such powerful change within the context of cardiovascular disease and high blood pressure.
Non-communicable diseases, of which cardiovascular diseases are by far the most common, are the main cause of mortality and disability worldwide.
The World Health Organisation has set nine global targets to achieve a 25% reduction in premature death from these diseases by 2025, defined as death before the age of 70 years, of which up to 80% can be prevented.
The global targets include a direct target to reduce cardiovascular diseases (heart disease and stroke) by 25%, and separate targets for dietary salt (sodium), harmful alcohol use, inactivity, tobacco use, obesity and increasing access to essential medications.
Official South African statistics report 81 782 deaths from cardiovascular diseases in 2015, representing 17.8% of total mortality. This excludes another 3% attributed to diabetes, of which most people will also suffer cardiovascular disease.
This means one in every five will die from heart disease and strokes. The impact reaches much further though, reducing quantity and quality of life, lessening household income and straining the national economy.
Excess dietary salt intake that has been high on the national health agenda since legislation was gazetted in 2013.
Many have asked whether these tiny white crystals really merit so much attention? The answer starts with the patterns of high blood pressure in South Africa.
The recently released South African Demographic and Health Survey reported blood pressure levels from a representative national sample of nearly 8 000 adults.
An alarming 46% of women and 44% of males were classified as hypertensive by either elevated systolic or diastolic blood pressure, or by use of medication to control high blood pressure.
The Western Cape was the worst performer, with prevalences for both males and females of over half the adult population. This continues the pattern seen in several recent surveys, with the prevalence of high blood pressure steadily climbing.
The WHO estimates that half of all strokes and 40% of heart attacks can be attributed to high blood pressure. Over half of South Africans are unaware of their high blood pressure, and even those in the know, too few are prescribed medication or adhere to it.
Blood pressure has a complex aetiology, and excess salt intake can by no means carry all the blame. Factors such as genetic susceptibility, obesity, smoking, physical inactivity and stress levels all play instrumental roles.
Salt intake should also be seen in context to the rest of the diet, particularly potassium intake (i.e. fruit and vegetables), and relative to other factors such as exercise, body size and existing medical conditions. Why all the emphasis on salt then?
The WHO recommends a daily salt limit of five grams a day, which equates to roughly a teaspoon of salt from food and added to food.
With a meaningful reduction in salt intake, systolic blood pressure can be expected a drop by as much as 5mmHg (millimetre of mercury) to 10mmHg.
While this may seem a small improvement, it is clinically significant.
Multiply this by the number of people who live with high blood pressure, many of whom are untreated, and the benefit becomes immense.
A 2012 simulation study predicted that a population reduction of only 0.85g salt per person per day can save 7 400 lives and prevent 4 300 non-fatal strokes every year in South Africa alone.
It is within this context that the WHO has labelled salt reduction a “best buy” - an intervention that is very feasible on the public scale and can provide large-scale benefit.
The SA National Department of Health has heeded this call, and imposed restrictions on the salt content for a basket of typical salty foods since June 2016, with further reductions to follow in 2019.
These regulations were progressive and the impact can already be seen with foods such as breads, breakfast cereals and stock cubes containing less salt than before. Is this enough though? It’s a great start, but no, it certainly is not enough.
Legislated changes to sodium levels in certain processed foods will reduce salt intake by about one gram per person. With the average person eating nearly 10g of salt a day, a further reduction is needed. The most effective way to achieve this, is to consider how salt is used in cooking and at the dinner table.
Salt is added liberally during cooking, often to already salt laden foods. Salt is also the main ingredient of many other spices such as stock cubes, soup powders, soya sauce, barbeque or chicken spice, to name but a few.
The assault does not end there, a third of South Africans add salt to their meals at the table before tasting their food.
A 2013 online survey explored the daily salt habits of 7 000 participants, including 1 000 South Africans. Average estimated salt intake was 9.5g a day, double the recommended intake. Irrespective of their actual intake, the vast majority of respondents rated their own salt intake as normal.
Accurately assessing your own salt intake is a big obstacle to eating the right amount of salt. Mostly because most salt is not seen, and taste buds becomes desensitised with ongoing exposure to an overly salty diet.
Salt awareness is further impeded by food packaging information that is difficult to interpret, and the widespread use of added salt in most processed foods. It is therefore not surprising that the average South African eats significantly more salt than the maximum recommendation of five grams a day.
Sustained behaviour change is never easy. Salt is an excellent example as both a habit and a taste preference that is acquired over many years.
However, initiatives in other countries such as the UK and Finland have successfully reduced salt consumption through food reformulation and driving public awareness.
In South Africa, legislated changes will bring about a significant shift in salt use, and studies are under way to monitor this. Concurrent awareness campaigns and education can lead to an even greater reduction, and greater improvements in blood pressure.
The Heart and Stroke Foundation SA implemented the multi-stakeholder awareness campaign, Salt Watch, from 2014 to 2016. Results from this campaign show an encouraging shift towards a greater awareness and intention to use less salt. However, this is a message that needs repetition to reach all South Africans.
The Heart and Stroke Foundation SA, together with the support of the National Lotteries Commission and Department of Health, is excited to launch a salt reduction campaign to emphasise the importance of using less salt during Heart Awareness Month in September 2017 and bring a fresh and contemporary message to shift thinking about salt use.
The foundation would also like to remind all readers to have their blood pressure checked in September.
Every adult should have his or her blood pressure checked yearly, and our sponsor, Dis-chem Pharmacies, has made free testing of blood pressure, cholesterol and blood glucose available for the entire month of September, nationwide.
Visit www.heartfoundation.co.za for more information.
Gabriel Eksteen, MSc RD. & Megan Lee RD for the Heart and Stroke Foundation SA