Ireland has one of the highest rates of high blood pressure in the world – mandatory limits on salt in bread could change all that in a few years

Excessive salt in food is causing major damage and illness to Irish people, but the situation can be radically changed as has been proven in Korea and other countries writes Dr Catherine Conlon

As the latest check of the nation’s health in Health in Ireland: Key Trends 2025 was published, Health Minister Jennifer Carroll McNeill highlighted how Ireland has made large strides in recent years. “We have the eighth highest life expectancy in the EU, and the highest self- reported good health,” the Minister said.

What was not revealed in the figures, is that Ireland has one of the highest rates of high blood pressure (BP) in the world, as well as ranking among the lowest in terms of diagnosis, treatment and control of the condition.

This matters, because high blood pressure, the ‘silent killer’, significantly increases the risk of heart attack, stroke, kidney disease and premature death. Yet, early detection, regular monitoring and sustained treatment can prevent most conditions caused by sustained high BP.

Just over half (55 per cent) of ischaemic heart disease, half (50 per cent) of ischaemic stroke and more than half (58 per cent) of other cardiovascular conditions have been attributed to high BP. It is the single biggest risk factor globally for ‘all cause mortality’ leading to just under 10 million deaths a year with 1.4 billion people affected.

A study in the Lancet (2021) of people from 12 high-income countries, found that Irish men and women were least likely to have been diagnosed with high blood pressure, given medication to treat it, or to have it controlled.

Treatment is a combination of medication and lifestyle factors; including weight management, physical activity, salt restriction, alcohol reduction and smoking cessation.

However, one country has shown astounding success in the management of hypertension, demonstrating just what can be achieved with sustained political will. Over three decades, Korea has manage to cut stroke deaths by a remarkable 80 per cent. How did they do it?

Former director of the Centres for Disease Control and Prevention and NYC Health Commissioner, Dr Tom Frieden, described in his recent newsletter the policy changes that caused this achievement.

In 1990, stroke killed South Koreans at a rate of 248 per 10,000. By 2023, that had dropped like a stone to 32 – a fall of 87 per cent.

This was achieved by a series of deliberate choices, sustained across successive governments, leading to plummeting hospitalisations, disability, strokes and heart attacks.

“The story deserves to be much better known,” said Dr Frieden, “because Korea has earned the credit and because every country in the world can make progress at least this fast.”

Rather than investing in awareness campaigns, the first step was to ensure every adult had a regular medical provider whose job it was to keep blood pressure in check, and their performance was measured on how well they achieved it. Health professionals were required to identify people at risk, follow them up and record their successes.

Ireland has one of the highest rates of high blood pressure (BP) in the world, as well as ranking among the lowest in terms of diagnosis, treatment and control of the condition

Secondly, in 2012 the government implemented a National Plan to Reduce Sodium Intake – working with manufacturers, restaurants, schools and households to cut salt out of the national diet. The government funded research to help companies reformulate their products.

Within a few years, Koreans had reduced their sodium intake by almost a quarter, with plummeting rates of stroke and heart disease.

“None of this required exceptional technology, wealth, or anything specific to Korean culture,” Dr Frieden concluded. “A group of dedicated advocates pushed for it and never gave up. The ingredients for success – a regular provider, consistent treatment, free medicines, and smart food policy – are possible in most countries.”

In Ireland, one-in-four deaths are due to cerebrovascular disease and, despite good news stories about improvements in life expectancy, it is estimated that an incredible 80 per cent of premature heart disease and stroke is preventable.

In late 2023, the Irish Heart Foundation launched Primary Prevention of cardiovascular disease: Best practice and lessons for Ireland.

The paper, compiled by Prof Ivan Perry from the School of Public Health, University College Cork, recommended radical action – similar to Ireland’s 2004 ban on smoking in the workplace – to deal with cardiovascular disease and other serious diseases.

“Without the implementation of bold policy initiatives, we can expect continued and increased deaths and ill-health driven by risk factors,” warned Prof Perry.

Key recommendations include a complete ban on the marketing of food and drinks high in fat, sugar and salt, and an increase in the legal age of tobacco from 18 to 21 – now due to be implemented in February 2021.

But the evidence shows that a mandatory limit on salt in the manufacture of bread and other processed foods leads the way as the cheapest strategy to reduce cardiovascular disease.

Cardiovascular disease is one of the leading causes of death and disability in Ireland – accounting for almost 10,000 deaths every year. This represents almost a third (30 per cent) of all deaths every year. Diet is a key risk factor – via indirect effects on risk factors such as body weight, diabetes and blood pressure.

Another critical risk factor is salt. As BP rises, so does the risk of heart disease and stroke. But contrary to what you might expect, most heart and stroke events happen at the lower end of the BP scale of approximately 130mmg Hg/ 80mm Hg because of the large numbers of the population with BP at this level.

Given that clinical guidance does not recommend treatment at the lower end of the BP scale with medication, population-wide interventions that focus on the underlying causes of BP – including suboptimal diet, physical inactivity, and alcohol intake in the whole population, are critical to reducing the levels of heart disease and stroke in the country.

The Korean success story is a case in point of just how much impact these nationwide interventions can have in causing heart disease and stroke to rapidly plummet.

In 2022, Spain introduced a mandatory limit of 1.31 g of salt per 100g of bread (13.1g of salt per kg of bread). The mandatory upper limit was announced in 2019, giving the industry three years to make the required adjustments. Prof Perry noted in his report in 2023 that mandatory reformulation is permissible under current EU single market regulations.

“We recommend that Ireland adopt a similar approach and specify mandatory upper limits to the salt content of bread, and other major sources of salt in the Irish diet, such as processed meat, with a two-to-three year lead time.

“This would lead to significant reductions in population-level salt intakes in Ireland, with a positive impact on cardiovascular disease morbidity and mortality.”

He added that the impact would be greatly advanced if it formed part of a suite of measures that included food labeling (front of pack), public sector procurement, and mass media campaigns, similar to approaches used in Finland and Japan.

A comprehensive, evidence based report has spelt out the benefits of mandatory limits on the salt content of bread and processed meat to significantly reduce deaths and illness from heart disease and stroke in an ageing population.

How long before the Minister for Health, Jennifer Carroll McNeill and the Department of Health see it that way?

Author
Dr Catherine Conlon is a public health doctor in Cork.