P1003 AWASH submission May 2008
AWASH is the Australian Division of World Action on Salt and Health
Comments on Key Issues for Consideration at Final Assessment (May 2008)
1. Salt reduction is a public health priority in Australia
People only need very small amounts of salt to be healthy and most Australians eat much more salt than they need. Reducing dietary salt intake lowers blood pressure for most people.
Getting salt consumption down to the Upper Limit recommended by the NHMRC (no more than 6 grams a day) would be likely to prevent about a fifth of all strokes and heart attacks in Australia each year. Even healthy people with normal blood pressure stand to gain significant long-term health benefits from cutting salt out of their diets.
The Australian Division of World Action on Salt and Health (AWASH), a growing network of representatives from the medical profession, scientific community, food industries, consumer associations, education and health promotion bodies, launched the Drop the Salt! campaign. The primary goal is to reduce the average amount of salt consumed by Australians to 6 grams per day within the next five years. There will be four main objectives:
- An average 25% reduction in the salt content of processed foods
- An average 25% reduction in salt use by the catering industry
- Increased population knowledge of the benefits of low salt diets
- Clear labelling of foods that makes the salt content immediately apparent.
For more information see: www.awash.org.au.
2. Adequate monitoring of iodine status
If, as anticipated, there is a reduction in the amount of salt used by the industry (retailers and manufacturers) of 25% over the next 5 years, it is likely that the salt content of bread will fall. A recent WHO workshop noted that with the trend for a world reduction in salt intake there may be a need to increase the amount of iodine added to salt.1 The proposal for Australia is that iodised salt (25-65 mg of iodine per kg of salt) be used in most breads to increase the average dietary intake of iodine of the population, but it is not clear if this strategy will be sufficient to reduce iodine insufficiency rates to acceptably low levels in all population groups. In this environment where there is likely to be a reduction in the salt added to manufactured foods over time, only the implementation of a systematic program of monitoring iodine status (utilising urine collections) will determine if this strategy is effective in all groups. This monitoring program must be initiated prior to the implementation of the fortification program and must receive support and funding at federal and state levels on an ongoing basis, to monitor the effectiveness of the strategy over the long term.
3. Educational programs
It is important that any educational campaign to ensure adequate intakes of iodine does not conflict with the accepted health recommendations to reduce blood pressure through reducing dietary salt intake. It is acknowledged for example that even with the mandated use of iodised salt in bread, that the majority of Australian women are unlikely to meet their iodine requirements during pregnancy or lactation. For that reason an effective targeted educational campaign advising the use of vitamin supplements containing both iodine and folate is fundamental in ensuring that iodine requirements are met during pregnancy and lactation. Appropriate education messages also need to be developed for those groups who consume little or no bread. It is not acceptable to promote the use of iodised salt in cooking and/or at the table to ensure the iodine requirements are met in this population, and supplements and/or consumption of other foods high in iodine should be recommended to these groups where the mandatory use of iodised salt in bread will not ensure that their requirements are met. The whole population is at risk of developing high blood pressure and it is not appropriate to depend on added discretionary salt for distributing iodine, when both the WHO and NHMRC advise a reduction in salt intake2,3 and clearly the first practical step should be to remove the salt shaker.
4. Development of alternative strategies for the delivery of iodine
AWASH agrees that speed, convenience and economy make it legitimate to use iodised salt in bread as a quick response to Australia’s shortage of iodine. The recent WHO workshop acknowledged that the WHO endorsed recommendations for reduction in population salt intake worldwide conflicts with a health message to use iodised salt and that alternative vehicles for iodine delivery need to be investigated.4 Therefore the mandatory use of iodised salt in bread should be viewed as an interim measure and we should plan now for the change to a better strategy for iodine delivery, for example iodised bread flour.
There are two main reasons for this:
- There is public confusion and administrative difficulty of having conjoined food additives with opposite health messages – iodine (you need more because it is good for you) and salt (you need less because it is bad for you).
- There is wide variation in the amount of salt and there will potentially be a large variation in the concentration of iodine in the salt (25-65 mg of iodine per kg of salt, potentially a 2.6 fold difference in iodine concentration) which will produce very different doses of iodine from different bread products. The flour content of bread is, however, much more constant, moreover metering equipment would iodise the flour much more accurately using an iodine compound of constant composition (not iodised salt).
BRI Research (the former Bread Research Institute) has agreed that a folate and iodine premix suitable for metered addition to bread flour would be feasible and would have advantages. The development of this and other alternative methods of delivering iodine to the population will not occur unless there is significant financial engagement and investment from industry and/or the government.
The proposed mandatory use of iodised salt in bread is likely to improve the rates of iodine insufficiency and deficiency in Australia, but only ongoing systematic monitoring of the iodine status in different population groups will confirm that this strategy is effective and remains effective over time. There are real challenges in developing comprehensible consumer messages that encompass the health benefits of reducing dietary salt intake and value of consuming iodised salt in bread. It is clear that in the long-term other strategies, independent of iodised salt intake, will need to be developed to ensure adequacy of iodine intake.
- Implement the mandatory use of iodised salt in most breads in the first instance, but make sure that the importance of reducing salt intakes is communicated clearly as a priority to both the food industry and consumers in any communication about the use of iodised salt.
- Ensure that the accompanying educational campaign neither promotes nor requires the use of added salt at the table and/or cooking, and that supplements and/or other sources are promoted to those for whom the mandatory use of iodised salt in bread will not ensure that they receive sufficient dietary iodine.
- Implement a long-term monitoring system to assess the impact on iodine status across all population groups of the mandatory use of iodised salt in bread.
- Ensure that government provides financial incentives for industry to develop alternative methods of delivering iodine to the population of Australia and New Zealand.
Submitted by Jacqui Webster
On behalf of Secretariat of Australian Division of World Action on Salt and Health (AWASH)
The George Institute for International Health, Level 10 King George V Building, Royal Prince Alfred Hospital
PO Box M201 Missenden Road Sydney NSW 2050 Australia
Tel: +61 2 9993 4520 Fax: +61 2 9993 4502
- World Health Organisation. Iodine status worldwide: WHO Global Database on Iodine Deficiency. (Geneva: World Health Organisation ).
- Asaria, P., Chisholm, D., Mathers, C., Ezzati, M. & Beaglehole, R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco useLancet 370, 2044-2053 (2007).
- NHMRC. Nutrient Reference Values for Australia and New Zealand. Department of Health and Aging (2006).
- World Health Organisation. Reducing salt intake in populations. Report of a WHO forum and technical meeting. (Geneva, 2007).