Hypertension Prevention Dr Temo Waqanivalu Program Officer Surveillance and Population-based Prevention Unit Department of Prevention of Noncommunicable Diseases

Burden of NCD - In 2012 38 million deaths were due to NCD 10% Deaths in 2011 Age groups Source: WHO Global Burden of Disease (2011)

Burden of NCD

Prevalence of Raised Blood Pressure

Prevalence of Raised Blood Pressure

Causative or Contributing Factors

Leading risk factors for global mortality Source: WHO's report on "Global health risks" 60% of global death are due to non communicable diseases; That includes 15% of the total number of deaths with occurs before the age of 60, and 27% of the total number which occurs before the age of 70. High blood pressure is ranked 1th on global level Physical inactivity is ranked 4th on global level (5.5%) – overweight/obesity 4.8% - unsafe sex 7th with 4 %.

Strong evidence for the link between salt and health Primarily linked with CVD Sodium consumption increases BP BP increases CVD risk Age, sex and baseline BP specific effects . Source: He et al. J Human Hypertension, 2008

Dose Response: Meta-analysis (1 month or longer) Change in Systolic BP (mmHg) Normotensives b=0.04, P<0.001 Hypertensives b=0.07, P<0.001 Change in Urinary Sodium (mmol/24h) \ A 6 g/day reduction in salt intake predicts a fall in SBP of:  7 mmHg in Hypertensives (p<0.001)  Avg. 5 mmHg  4 mmHg in Normotensives (p<0.01) J Human Hypertens 2002;16:761

Salt Consumption Average 10g/day 80% from processed foods Mean Sodium Intake in persons 20 yrs and over 2010 Average 10g/day 80% from processed foods

 Salt intake 5-6g/day  Stroke 24%  CHD 18% 600,000 (approx) Stroke & heart attack deaths prevented / year Western Pacific Worldwide 2.0 million (approx) deaths prevented / year He & MacGregor. Hypertension 2003;42:1093-99

The Political Declaration of the High Level Meeting Article 43 12

Outcomes: mortality and morbidity Exposures: biological and behavioural risk factors National systems response Member States have committed themselves to "consider the development of national targets based on national situations", building on the 9 voluntary global targets. National targets can be more or less ambitious than the global ones and should be guided by: - Current performance; - Current level of exposure; - Programmes planned and in place. WHO is developing a Toolkit on NCD Surveillance, which will include a module on setting national targets and measuring results

WHO supports countries in addressing NCDs 2000 WHO Global Strategy for the Prevention and Control of NCDs WHO Framework Convention on Tobacco Control 2003 WHO Global Strategy on Diet, Physical Activity and Health 2004 WHO Global NCD Action Plan 2008-2013 2008 WHO Global Strategy to Reduce the Harmful Use of Alcohol 2009 First WHO Global Status Report on NCDs 2010 Moscow Declaration UN Task Force on NCDs 2011 2011 UN Political Declaration on NCDs 2013 2013 WHO Global NCD Action Plan 2013-2020, including 9 global targets 2014 2014 UN Outcome Document on NCDs 2015 2015 Country Framework for Action to engage sectors beyond health on NCDs Adoption of the post-2015 development agenda 2025 World Health Assembly Attainment of the 9 global targets for NCDs by 2025 UN General Assembly 2030 Attainment of the global target for NCDs by 2030 (as part of the Sustainable Development Goals) ECOSOC

The WHO Global NCD Action Plan 2013-2020 – six objectives

The Approach 16

High risk and Population-based approaches High-Risk Approach Population Approach Benefit is high for… The whole population The individual Source: Rose G. “Sick Individuals and Sick Populations” IJE 2001;30:427-432 Subject motivation Low High Doctor motivation Benefit-risk ratio “Worrisome” “Favourable” Screening costs No screening costs High Depth of solution Radical Palliative, temporary Behaviour-Context fit “Appropriate” “Inappropriate”

Very Cost Effective (Best Buy) Intervention

Causes of Causes/Determinants Development? ENVIRONMENTAL Socio-cultural Economic & Trade Physical 5000yrs ago average world intake of salt 0.1g/day To preserve food and clean bad ones Development result in refrigeration and chemicals Now 9-12 g/day

Guidelines

SALT (Sodium) Guidelines For adults: WHO recommends that adults consume less than 5 g (just under a teaspoon) of salt per day. For children: WHO recommends that the recommended maximum intake of salt for adults be adjusted downward for children aged two to 15 years based on their energy requirements relative to those of adults. All salt that is consumed should be iodized or “fortified” with iodine

Population Salt Reduction Strategies INDUSTRY ACTION Product Reformulation Food Regulations Reduction of salt in processed foods Industry Commitment Food Targets/Standards Proper labeling Fiscal Measures WHAT HOW OUTCOME Local Policies Catering Guidelines Marketing & Mobilization Consumer Education Reduction of use and consumption of salt Public Awareness and education campaign Behavior Change campaign Health Literacy Reduction of use of salt Food outlets Events and functions Settings (Schools, Health Care Facilities) 1 EMPOWER CONSUMERS 2 SUPPORTIVE SETTINGS 3 http://www.who.int/dietphysicalactivity/reducingsalt/en/

Hidden Salt in food ↓ BP Food industry slowly reduce e.g. processed, fast, takeaway, restaurant food Food industry slowly reduce - No rejection by public Fantastic for Public Health Very little cost ↓ BP No need to change diet

How not to ↓ salt ! No effect on salt intake Give choice of reduced salt products No effect on salt intake Allow industry to claim no one wants it Does not target most deprived Allow some health charities to get money from food industry!

M&E Framework

Population Based Prevention in country Establish Baseline level of risk and set national targets Develop national multisectoral plans with other sectors including private and CSOs Implement equitable actions focused on poor and vulnerable Monitor implementation and trends Networking

Progress so far .. All regions except Africa are conducting surveys and initiating salt reduction measures All regions are progressing Physical activity promotion since the global target set Marketing Restrictions and dietary fiscal policies poorly implemented by all Fruits and vegetable promotion to be strengthened through Nutrition Decade of Action (ICN2) MORE NEEDS TO BE DONE

The WHO Global NCD Action Plan 2013-2020 – six objectives with recommended actions for Member States, international partners and WHO Action for Secretariat (WHO) LEADING & CONVENING: Work with the United Nations funds, programs and agencies to reduce modifiable risk factors at the country level POLICY ADVICE & DIALOGUE: Publish and disseminate guidance (“toolkits”) on the implementation and evaluation of interventions at the country level for reducing the prevalence of tobacco use, promoting a health diet and physical activity and reducing the harmful use of alcohol NORMS & STANDARDS: continue to build on existing efforts and develop normative guidance and technical tools to support the implementation of WHO’s global strategies for addressing modifiable risk factors; KNOWLEDGE GENERATION: Strengthen the evidence base and disseminate evidence to support policy interventions at the country level for reducing the prevalence of tobacco use, promoting a healthy diet and physical activity and reducing the harmful use TECHNICAL COOPERATION: Provide technical assistance to reduce modifiable risk factors including through implementing the WHO guidelines and global strategies for addressing modifiable risk factors and other health-promoting policy options. Bolding the bit that EMRO is doing through the Call for Action and this meeting -= to be emphasised

S A L T Toolkit trategy development ction to reduce salt ink to Iodine Fortification racking progress

Population Salt Reduction Strategies INDUSTRY ACTION Product Reformulation Food Regulations Reduction of salt in processed foods Industry Commitment Food Targets/Standards Proper labeling Fiscal Measures WHAT HOW OUTCOME Local Policies Catering Guidelines Marketing & Mobilization Consumer Education Reduction of use and consumption of salt Public Awareness and education campaign Behavior Change campaign Health Literacy Reduction of use of salt Food outlets Events and functions Settings (Schools, Health Care Facilities) 1 EMPOWER CONSUMERS 2 SUPPORTIVE SETTINGS 3 http://www.who.int/dietphysicalactivity/reducingsalt/en/

Thank You http://www.who.int/dietphysicalactivity/reducingsalt/enE mail: waqanivalut@who.int