Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use

Salt Reduction to Prevent Hypertension and Cardiovascular Disease: JACC State-of-the-Art Review

There is strong evidence for a causal relationship between salt intake and blood pressure. Randomized trials demonstrate that salt reduction lowers blood pressure in both individuals who are hypertensive and those who are normotensive, additively to antihypertensive treatments. Methodologically robust studies with accurate salt intake assessment have shown that a lower salt intake is associated with a reduced risk of cardiovascular disease, all-cause mortality, and other conditions, such as kidney disease, stomach cancer, and osteoporosis. Multiple complex and interconnected physiological mechanisms are implicated, including fluid homeostasis, hormonal and inflammatory mechanisms, as well as more novel pathways such as the immune response and the gut microbiome. High salt intake is a top dietary risk factor. Salt reduction programs are cost-effective and should be implemented or accelerated in all countries. This review provides an update on the evidence relating salt to health, with a particular focus on blood pressure and cardiovascular disease, as well as the potential mechanisms.

Using Social Marketing to Reduce Salt Intake in Iran

Objectives: WHO has recommended that the average salt intake must be <5 grams per day. However, people consume salt much more in many countries. In this study, we design and implement an intervention based on social marketing model to reduce salt consumption in Yasuj, Iran. Materials and Methods: This study employed a quasi-experimental pretest-posttest with control group design which consisted of a formative research (qualitative-quantitative) and an interventional phase. To collect the qualitative data, six focus group discussions by participating of 66 people were established. The qualitative data were analyzed manually using directed content analysis. In quantitative study, 166 people aged 25-50 years completed a KAP questionnaire, and their average salt intake was determined through measuring sodium in their urine sample. By analyzing the data, marketing mix components were determined for designing an intervention. An educational package (including posters for installing in the kitchen, pamphlets, phone counseling, four educational classes, and brief interventions done by physicians and other health personnel) focused on reducing salt intake and using alternatives was developed. For one month, program was implemented for intervention group. Two months later, KAP survey and measuring the urine sodium were repeated for intervention and control groups. The data was compared for two groups, before and after the intervention by using independent t-test, paired t-tests and repeated measures ANOVA. Results: The qualitative findings showed that most participants agreed that the salt intake was high in Iran. Most of them recommended home-based and family-driven strategies to reduce salt intake, offered using healthier alternatives for salt, and recognized physicians and health care providers in healthcare facilities as the most important to encourage people to reduce salt intake. After the intervention, the mean and standard deviation of KAP were improved significantly in intervention group. The mean salt intake decreased significantly by 3.01 ± 2.38 in the intervention group and repeated measures ANOVA showed significant change over time (P < 0.001) and a significant difference between two groups (P = 0.04)_. Also, the interaction between time and group was significant (P = 0.001). Conclusion: The mean salt intake among the study population was approximately three times more than the level recommended by the WHO. The social marketing-based intervention succeeded in reducing the salt intake of the study subjects by ~3 grams on average.

A Comparison of Strategies to Improve Population Diets: Government Policy versus Education and Advice

Different strategies have been utilized in order to improve the healthiness of the population diet. Many interventions employ education, advice, and encouragement (EAE). Those interventions have been carried out in diverse settings and may achieve modest success; the estimated risk of cardiovascular disease is lowered by about 5–15%. An alternative strategy is action policies carried out by the governments. The removal of trans-fatty acids from food is a model for a successful action policy. Other action policies include requiring a substantial reduction in the amount of salt added to processed foods and ordering schools to cease supplying unhealthy food to students. Taxes and subsidies can be used to increase the price of unhealthy foods, such as sugar-rich foods, and reduce the price of healthy foods, such as fruit and vegetables. It is very probable that action policies are more effective than those based on EAE. They are also much more cost-effective.

From the micro to the macro to improve health: microorganism ecology and society in teaching infectious disease epidemiology

Chronic and emerging infectious diseases and antimicrobial resistance remain a substantial global health threat. Microbiota are increasingly recognised to play an important role in health. Infections also have a profound effect beyond health, especially on global and local economies. To maximise health improvements, the field of infectious disease epidemiology needs to derive learning from ecology and traditional epidemiology. New methodologies and tools are transforming understanding of these systems, from a better understanding of socioeconomic, environmental, and cultural drivers of infection, to improved methods to detect microorganisms, describe the immunome, and understand the role of human microbiota. However, exploiting the potential of novel methods to improve global health remains elusive. We argue that to exploit these advances a shift is required in the teaching of infectious disease epidemiology to ensure that students are well versed in a breadth of disciplines, while maintaining core epidemiological skills. We discuss the following key points using a series of teaching vignettes: (1) integrated training in classic and novel techniques is needed to develop future scientists and professionals who can work from the micro (interactions between pathogens, their cohabiting microbiota, and the host at a molecular and cellular level), with the meso (the affected communities), and to the macro (wider contextual drivers of disease); (2) teach students to use a team-science multidisciplinary approach to effectively integrate biological, clinical, epidemiological, and social tools into public health; and (3) develop the intellectual skills to critically engage with emerging technologies and resolve evolving ethical dilemmas. Finally, students should appreciate that the voices of communities affected by infection need to be kept at the heart of their work.

Cluster randomised controlled trial of home cook intervention to reduce salt intake in China: a protocol study

INTRODUCTION

Salt intake in China is twice the upper limit recommended by the WHO, and nearly 80% of salt is added during cooking. This study will develop a package of salt reduction interventions targeting home cooks and evaluate its effectiveness and feasibility for scale-up.

METHODS AND ANALYSIS

A cluster randomised controlled trial design is adopted in this study, which will be conducted in six provinces covering northern, central and southern China. For each province, 10 communities/villages (clusters) with 13 families (one cook and one adult family member) will be selected in each cluster for evaluation. In total, 780 home cooks and 780 adult family members will be recruited. The home cooks in the intervention group will be provided with the intervention package, including community-based standardised offline and online health education and salt intake monitoring. The duration of the intervention will be 1 year. The primary outcome is the difference between the intervention and control group in change in salt intake as measured by 24 hours urinary sodium from baseline to the end of the trial. The secondary outcome is the difference between the two groups in the change in salt-related knowledge, attitude and practice and blood pressure (BP).

ETHICS AND DISSEMINATION

The study has been approved by The Queen Mary Research Ethics Committee (QMERC2018/13) and Institutional Review Board of the Chinese Center for Disease Control and Prevention (No. 201801). The study findings will be disseminated widely through conference presentations and peer-reviewed publications and the general media.

TRIAL REGISTRATION NUMBER

ChiCTR1800016804.

Design and implementation of an intelligent monitoring system for household added salt consumption in China based on a real-world study: a randomized controlled trial

BACKGROUND

A high intake of salt is a major risk factor for cardiovascular diseases. Despite decades of effort to reduce salt consumption, the salt intake in China is still considerably above the recommended level. Thus, this study aims to design and implement an intelligent household added salt monitoring system (SALTCHECKER) to monitor and control added salt consumption in Chinese households.

METHODS

A randomized controlled trial will be conducted among households to test the effect of a SALTCHECKER in Chongqing, China. The test modalities are the SALTCHECKER (with a smart salt checker and a salt-limiting WeChat mini programme) compared to a salt checker (with only a weighing function). The effectiveness of the system will be investigated by assessing the daily added salt intake of each household member and the salt consumption-related knowledge, attitude and practice (KAP) of the household's main cook. Assessments will be performed at baseline and at 3 and 6 months.

DISCUSSION

This study will be the first to explore the effect of the household added salt monitoring system on the reduction in salt intake in households. If the intelligent monitoring system is found to be effective in limiting household added salt consumption, it could provide scientific evidence on reducing salt consumption and preventing salt-related chronic diseases.

TRIAL REGISTRATION

Chinese clinical trial registry (Primary registry in the World Health Organization registry network): ChiCTR1800018586. Date of registration: September 25, 2018.

Reducing Salt Intake in China with "Action on Salt China" (ASC): Protocol for Campaigns and Randomized Controlled Trials

BACKGROUND

Salt intake in China is over twice the maximum recommendation of the World Health Organization. Unlike most developed countries where salt intake is mainly derived from prepackaged foods, around 80% of the salt consumed in China is added during cooking.

OBJECTIVE

Action on Salt China (ASC), initiated in 2017, aims to develop, implement, and evaluate a comprehensive and tailored salt reduction program for national scaling-up.

METHODS

ASC consists of six programs working in synergy to increase salt awareness and to reduce the amount of salt used during cooking at home and in restaurants, as well as in processed foods. Since September 2018, two health campaigns on health education and processed foods have respectively started, in parallel with four open-label cluster randomized controlled trials (RCTs) in six provinces across China: (1) app-based intervention study (AIS), in which a mobile app is used to achieve and sustain salt reduction in school children and their families; (2) home cook-based intervention study (HIS), in which family cooks receive support in using less salt; (3) restaurant-based intervention study (RIS) targeting restaurant consumers, cooks, and managers; and (4) comprehensive intervention study (CIS), which is a real-world implementation and evaluation of all available interventions in the three other RCTs. To explore the barriers, facilitators, and effectiveness of delivering a comprehensive salt reduction intervention, these RCTs will last for 1 year (stage 1), followed by nationwide implementation (stage 2). In AIS, HIS, and CIS, the primary outcome of salt reduction will be evaluated by 24-hour urinary sodium excretion in 6030 participants, including 5436 adults and 594 school children around 8-9 years old. In RIS, the salt content of meals will be measured by laboratory food analysis of the 5 best-selling dishes from 192 restaurants. Secondary outcomes will include process evaluation; changes in knowledge, attitude, and practice on salt intake; and economic evaluation.

RESULTS

All RCTs have been approved by Queen Mary Research Ethics Committee and the Institutional Review Boards of leading institutes in China. The research started in June 2017 and is expected to be completed around March 2021. The baseline investigations of the four RCTs were completed in May 2019.

CONCLUSIONS

The ASC project is progressing smoothly. The intervention packages and tailored components will be promoted for salt reduction in China, and could be adopted by other countries.

TRIAL REGISTRATION

Chinese Clinical Trial Registry. AIS: ChiCTR1800017553; https://tinyurl.com/vdr8rpr. HIS: ChiCTR1800016804; https://tinyurl.com/w8c7x3w. RIS: ChiCTR1800019694; https://tinyurl.com/uqkjgfw. CIS: ChiCTR1800018119; https://tinyurl.com/s3ajldw.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15933.

Elevated Blood Pressure and Associations with Sodium Intake Among Multiethnic Youth in Edmonton, Canada: Findings from WHY ACT NOW

INTRODUCTION

This study examined the prevalence of pre-hypertension (PHT) and hypertension (HT) in urban youth, and assessed the effects of sodium intake and obesity on blood pressure (BP) by ethnicity.

METHODS

A convenience sample of 557 multiethnic youth, aged 11-23 years, was recruited from 12 schools and institutions in Edmonton, Alberta, Canada. Participants were divided by self-identified ethnicity into four groups (Indigenous, African and Middle Eastern (AME), Asian, and European).

RESULTS

Between October 2013 and March 2014, one-on-one interviews were conducted to collect data on demographics, physical activity, diet, and Body Mass Index (BMI). BP was obtained at two different times during the interview and measured a third time in cases of high variability. The standard deviation scores (SDS) of systolic BP (SBP) and diastolic BP (DBP) were used to estimate associations with sodium intake (per 1000 mg/day). Overall, 18.2% and 5.4% of the participants had PHT and HT, respectively. Indigenous and AME participants showed the highest rates of PHT (23.1%). Indigenous and European participants showed higher rates of HT (8.3% and 5.3%, respectively) than other ethnic groups (AME = 4.4%, Asian = 3.9%). There was a positive association between 1000 mg/day increase in sodium intake and SDS of SBP by 0.041 (95% CI 0.007-0.083; p = 0.04) among pre-hypertensive participants. Over 85% of participants exceeded the recommended dietary sodium intake. Mean BMI and dietary sodium intake were higher among pre-hypertensive participants (4219 mg/day) than normotensive (3475 mg/day).

CONCLUSIONS

The prevalence of HT varied by ethnicity. High dietary sodium intake was of concern. There is a need for culturally-tailored, population-based interventions to reduce sodium intake.

Sodium Imbalance in Mice Results Primarily in Compensatory Gene Regulatory Responses in Kidney and Colon, but Not in Taste Tissue

Renal excretion and sodium appetite provide the basis for sodium homeostasis. In both the kidney and tongue, the epithelial sodium channel (ENaC) is involved in sodium uptake and sensing. The diuretic drug amiloride is known to block ENaC, producing a mild natriuresis. However, amiloride is further reported to induce salt appetite in rodents after prolonged exposure as well as bitter taste impressions in humans. To examine how dietary sodium content and amiloride impact on sodium appetite, mice were subjected to dietary salt and amiloride intervention and subsequently analyzed for ENaC expression and taste reactivity. We observed substantial changes of ENaC expression in the colon and kidney confirming the role of these tissues for sodium homeostasis, whereas effects on lingual ENaC expression and taste preferences were negligible. In comparison, prolonged exposure to amiloride-containing drinking water affected β- and αENaC expression in fungiform and posterior taste papillae, respectively, next to changes in salt taste. However, amiloride did not only change salt taste sensation but also perception of sucrose, glutamate, and citric acid, which might be explained by the fact that amiloride itself activates bitter taste receptors in mice. Accordingly, exposure to amiloride generally affects taste impression and should be evaluated with care.

A Brief Review of Nutraceutical Ingredients in Gastrointestinal Disorders: Evidence and Suggestions

The dietary effect on gut health has long been recognized through the empirical practice of soothing gastric discomfort with certain types of food, and recently the correlation between specific diets with lower incidences of several gastrointestinal diseases has been revealed. Ingredients from those considered beneficial foods have been isolated and studied, and some of them have already been put into the supplement market. In this review, we focus on latest studies of these food-derived ingredients for their proposed preventive and therapeutic roles in gastrointestinal disorders, with the attempt of drawing evidence-based suggestions on consuming these products.

The global burden of neurological disorders: translating evidence into policy

Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. In the past 30 years, the absolute numbers of deaths and people with disabilities owing to neurological diseases have risen substantially, particularly in low-income and middle-income countries, and further increases are expected globally as a result of population growth and ageing. This rise in absolute numbers of people affected suggests that advances in prevention and management of major neurological disorders are not sufficiently effective to counter global demographic changes. Urgent measures to reduce this burden are therefore needed. Because resources for health care and research are already overstretched, priorities need to be set to guide policy makers, governments, and funding organisations to develop and implement action plans for prevention, health care, and research to tackle the growing challenge of neurological disorders.

A pilot study on efficacy and safety of a new salt substitute with very low sodium among hypertension patients on regular treatment

OBJECTIVES

To understand the possible effect of a novel salt substitute with very low sodium in reducing blood pressure, salt intake and use of anti-hypertensive medications among patients on regular medications, to inform the future randomized trials.

DESIGN

Single-arm pilot trial.

SETTING

A community health service center in Chongqing, China.

PARTICIPANTS

A total of 43 patients with hypertension taking anti-hypertensive medications regularly.

INTERVENTION

Patients received the salt substitute with 18% sodium chloride for 8 weeks.

MAIN OUTCOME MEASURES

Patients were followed up weekly for the use of antihypertensive medications and measurements of blood pressure. We collected 24-h urine before and after the trial to measure sodium and potassium intake.

RESULTS

Among 39 patients who completed the 8 weeks' intervention, 30.8% patients stopped or reduced anti-hypertensive medications during the trial. For patients that stopped or reduced medication, the mean SBP and DBP before intervention were 122.1 ± 9.6 and 68.9 ± 9.4 mm Hg and both did not increase after intervention (SBP change: 2.8 mm Hg (-5.1, 10.8), P = .48; DBP change: 1.8 mm Hg (-2.2, 5.7), P = .38). For the rest patients, the mean SBP and DBP before intervention were 141.6 ± 16.9 and 74.6 ± 6.6 mm Hg but reduced significantly after the intervention (SBP change: -16.0 mm Hg (-21.3, -10.6), P < .001; DBP change: -5.5 mm Hg (-8.1, -2.9), P < .001). The 24-h urine sodium decreased (P < .001) and potassium increased (P < .001) among all patients. No severe adverse events were reported.

CONCLUSIONS

The novel salt substitute showed potential in reducing blood pressure and use of antihypertensive medications. Further randomized double-blind controlled trial is warranted to validate these findings.Clinical Trial Registration-URL:http://www.clinicaltrials.gov. Unique identifier: NCT03226327.

Salt consumption and the risk of chronic diseases among Chinese adults in Ningbo city

Background

Chronic diseases have become one of essential public health concerns, leading causes of mortality in China. It is related to the changes in dietary pattern and dietary behavior. The objectives are to assess daily salt intake in Chinese people living in Ningbo and to examine its relationship with health outcomes.

Methods

Our study used data from health and nutrition survey in 2017. This study included 2811 adults aged 18–79 years (48% males) from urban and rural areas in Ningbo. A food frequency questionnaire together with demographic, physical and medical questionnaires was used to collect dietary intake, demographic, lifestyle and medical information. Ordinal logistic regression was used in the statistical analysis.

Results

The mean daily salt intake (13.0 g/day) of the participants was higher than the Chinese dietary reference intake (DRI, 6 g/d), which was related to higher risk of pre-hypertension and hypertension. Stratified by gender, education and lifestyle factors, daily salt intake was only significant in the blood pressure category (male: P = 0.048; less education: P = 0.003; urban: P = 0.006; no regular physical activity: P = 0.005, no regular smoking: P = 0.006). Ordinal logistic regression model shows that daily salt intake was significantly associated with higher odds of developing hypertension.

Conclusion

The daily salt intake of the majority of citizens living in Ningbo exceeded Chinese DRI and may increase the risk of hypertension. Moreover, public health intervention of salt restriction is necessarily needed for the prevention and control the ongoing epidemic of chronic diseases.

Discretionary Salt Intake and Readiness for Behavioral Change Among Women in Tehran

Background:

Since women's readiness for dietary behavioral change can be one of the most effective fundamental measures for reducing dietary salt intake in line with preventing chronic diseases in developing countries, the present study is aimed to determine the readiness for behavioral change in discretionary salt intake among women living in Tehran.

Methods:

The present cross-sectional study was conducted on 561 women referring to the women care units across city of Tehran. The self-administered questionnaire included assessment of nutrition-related knowledge on salt intake and its association with diseases, discretionary salt intake, stages of change, and self-efficacy of women. In addition, the logistic regression test was used to determine the predictors of women's readiness for behavioral change in discretionary salt intake.

Results:

40% women had someone in the family who had such a limitation (salt intake-limited exposure group), while 81.6% always or often added salt to their foods. Moreover, one-third of the participants were in the stage of pre-contemplation and 41.2% were in the stage of preparation for reducing salt intake. Self-efficacy and salt intake-limited exposure were the two most important determinants of the women's readiness for behavioral change in discretionary salt intake, respectively: (OR = 1.1 95% CI: 1.06--1.14 P < 0.001; OR = 1.58, 95% CI: 1.03--2.42 P < 0.03).

Conclusions:

Results of the present study showed that increased self-efficacy is associated with higher levels of behavioral change among women. Since self-efficacy is very important for initiating and maintaining the behavioral change, women's empowerment for reducing salt intake necessitates putting the emphasis on increased self-efficacy as well as community-based nutritional interventions.

Projecting burden of hypertension and its management in Turkey, 2015-2030

BACKGROUND

In Turkey, hypertension was responsible for 13% of total deaths in 2015. We apply existing research finding regarding the impact of a population-wide reduction in sodium consumption on the decrease of the hypertension prevalence rate among 15+ years population and the gender-age specific reduction in total death rates among 30+ years population, and compare hypertension burden, averted deaths, costs and benefits between two scenarios.

METHODS

The first scenario (i.e. status quo) assumes constant hypertension prevalence rate and the death rates between 2015 and 2030. Based on the Framingham Heart Study and INTERSALT Study findings on the impact of salt-reduction strategies on hypertension prevalence rate, the second scenario (Scenario II) assumes a 17% reduction in the prevalence of hypertension in Turkey in 2030, from its 2015 prevalence level. We project hypertension attributable disability adjusted life years (DALYs) in 2030, monetize DALYs using GDP (and income) per capita, and compare the projected economic benefits of DALYs averted and the additional costs associated with the increases in hypertension treatment through antihypertensive medications and physician consultations.

RESULTS

The estimated benefits of reducing the economic burden of hypertension deaths outweigh the cost of providing hypertension treatment. A decrease in hypertension prevalence by 17%, attributable to population-wide reduction in salt consumption, is projected to avert 24.3 thousand deaths in 2030. We projected that, compared to status quo, 392 thousand DALYs will be averted in Scenario II in 2030. The economic benefits of reduction in potential hypertension deaths are estimated to be 6.7 to 8.6 folds higher than the additional cost of hypertension treatment.

CONCLUSION

Population-wide hypertension prevention and management is a win-win situation for public health and the Turkish health care system as the economic benefits of reducing deaths and disabilities associated with hypertension outweigh the costs significantly.

Three Public Health Interventions Could Save 94 Million Lives in 25 Years

BACKGROUND

Preventable noncommunicable diseases, mostly cardiovascular diseases, are responsible for 38 million deaths annually. A few well-documented interventions have the potential to prevent many of these deaths, but a large proportion of the population in need does not have access to these interventions. We quantified the global mortality impact of 3 high-impact and feasible interventions: scaling up treatment of high blood pressure to 70%, reducing sodium intake by 30%, and eliminating the intake of artificial trans fatty acids.

METHODS

We used global data on mean blood pressure levels and sodium and trans fat intake by country, age, and sex from a pooled analysis of population health surveys, and regional estimates of current coverage of antihypertensive medications, and cause-specific mortality rates in each country, as well, with projections from 2015 to 2040. We used the most recent meta-analyses of epidemiological studies to derive relative risk reductions for each intervention. We estimated the proportional effect of each intervention on reducing mortality from related causes by using a generalized version of the population-attributable fraction. The effect of antihypertensive medications and lowering sodium intake were modeled through their impact on blood pressure and as immediate increase/reduction to the proposed targets.

RESULTS

The combined effect of the 3 interventions delayed 94.3 million (95% uncertainty interval, 85.7-102.7) deaths during 25 years. Increasing coverage of antihypertensive medications to 70% alone would delay 39.4 million deaths (35.9-43.0), whereas reducing sodium intake by 30% would delay another 40.0 million deaths (35.1-44.6) and eliminating trans fat would delay an additional 14.8 million (14.7-15.0). The estimated impact of trans fat elimination was largest in South Asia. Sub-Saharan Africa had the largest proportion of premature delayed deaths out of all delayed deaths.

CONCLUSIONS

Three effective interventions can save almost 100 million lives globally within 25 years. National and international efforts to scale up these interventions should be a focus of cardiovascular disease prevention programs.

An Application-based programme to reinforce and maintain lower salt intake (AppSalt) in schoolchildren and their families in China

INTRODUCTION

Salt intake is very high in China, with ≈80% being added by the consumers. It is difficult to reduce salt in such settings. Our previous study (School-based Education programme to reduce Salt(School-EduSalt)) demonstrated that educating schoolchildren, who then instructed their families to reduce the amount of salt used at home, is effective in lowering salt intake in both children and adults. Our team also developed an app called 'KnowSalt', which could help individuals to estimate their salt intake and the major sources of salt in the diet. Building on School-EduSalt and KnowSalt, we propose to develop a new app (AppSalt) focusing on salt reduction through education, target setting, monitoring, evaluation, decision support and management to achieve a progressive lower salt intake for long term. To evaluate the effectiveness of the AppSalt programme, we will carry out a cluster randomised controlled trial.

METHODS AND ANALYSIS

We will recruit 54 primary schools from urban and rural areas of three provinces in China. A total of 594 children aged 8-9 years and 1188 adult family members will be randomly selected for evaluation. After baseline assessment, schools will be randomly allocated to either the intervention or control group. Children in the intervention group will be taught, with support of AppSalt, about salt reduction and assigned homework to get the whole family involved in the activities to reduce salt consumption. The duration of the intervention is two school terms (ie, 1 year). The primary outcome is the difference between the intervention and control group in the change of salt intake as measured by 24-hour urinary sodium.

ETHICS AND DISSEMINATION

The study has been approved by Queen Mary Research Ethics Committee and Peking University Health Science Centre IRB. Results will be disseminated through presentations, publications and social media.

TRIAL REGISTRATION NUMBER

ChiCTR1800017553.

Recommendations for the Establishment of Stroke Systems of Care: A 2019 Update

In 2005, the American Stroke Association published recommendations for the establishment of stroke systems of care and in 2013 expanded on them with a statement on interactions within stroke systems of care. The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating stroke systems of care to date and to update the American Stroke Association recommendations on the basis of improvements in stroke systems of care. Over the past decade, stroke systems of care have seen vast improvements in endovascular therapy, neurocritical care, and stroke center certification, in addition to the advent of innovations, such as telestroke and mobile stroke units, in the context of significant changes in the organization of healthcare policy in the United States. This statement provides an update to prior publications to help guide policymakers and public healthcare agencies in continually updating their stroke systems of care in light of these changes. This statement and its recommendations span primordial and primary prevention, acute stroke recognition and activation of emergency medical services, triage to appropriate facilities, designation of and treatment at stroke centers, secondary prevention at hospital discharge, and rehabilitation and recovery.

Application of Mobile Health Technologies Aimed at Salt Reduction: Systematic Review

Background

High salt consumption has contributed to the rise of noncommunicable diseases around the world. The application of mobile health (mHealth) technologies has witnessed rapid growth in recent years. However, evidence to support mHealth interventions to confront the challenge of salt reduction has not yet been critically reviewed.

Objective

The aim of this study was to identify, characterize, and evaluate mHealth interventions aimed at salt reduction across the world.

Methods

A systematic search of studies in English or Chinese language published from January 1, 1992 to July 31, 2017 was conducted using 4 English databases (PubMed, MEDLINE, Global Health, and Cochrane) and 3 Chinese databases (Wanfang, China Science and Technology Journal, and China National Knowledge of Infrastructure). All studies directly using mobile technologies in health care with a primary or secondary objective of reducing dietary salt consumption were included.

Results

A total of 1609 articles were found using the search strategy, with 11 full articles (8 English and 3 Chinese) being included for data extraction, including 11 interventional studies. Overall, few high-quality interventions were identified. Most interventions were limited by small study population sample sizes, lack of control groups, and short follow-up times, all of which were obstacles in generating long-term scalable approaches. Most interventions employed short message service as a platform for mHealth interventions, whereas some innovative mHealth technologies were also explored. Most interventions had a primary focus of improving awareness of dietary salt consumption. The outcome variables used to measure intervention effectiveness included 24-hour urinary sodium excretion, spot urine sampling, dietary records, and indirect behavior or knowledge indicators targeting salt consumption. Although most interventions displayed positive outcome results, none of them provided reliable evidence to evaluate the effectiveness of salt reduction.

Conclusions

Salt reduction in mHealth initiatives remains relatively unexplored; however, studies that did intervene on salt-reduction show the potential of mHealth as an effective intervention method. We provide 3 recommendations for future mHealth interventions in salt reduction—(1) increased use of new, innovative, and interactive mHealth technologies; (2) development of mHealth interventions with primary prevention measures and goals of salt reduction; and (3) large-scale, rigorously designed, and object-targeted clinical trials of mHealth interventions with appropriate quantitative outcome variables, in particular 24-hour urine sodium.

Understanding Barriers and Enablers to State Action on Salt: Analysis of Stakeholder Perceptions of the VicHealth Salt Reduction Partnership

The Victorian Salt Reduction Partnership (VicSalt Partnership) was launched in 2015, bringing together health and research organisations to develop an action plan for salt reduction interventions at a state level. A comprehensive evaluation was designed to assess the impact of the resulting four-year intervention strategy. As part of the process evaluation, semi-structured interviews were undertaken with stakeholders in March⁻May 2017, to understand perceived barriers and enablers to effective strategy implementation. Data were coded in relation to the key topic areas of the interviews with an inductive method used to analyse themes within topics. Seventeen stakeholders were contacted, 14 completed an interview; five from state government or statutory agencies, four from non-government funded organisations, four from research organisations and one from the food industry. Twelve were members of the VicSalt Partnership and two were informal collaborators. Most stakeholders viewed the VicSalt Partnership as a positive example of working collaboratively, and said this was essential for raising awareness of the importance of salt reduction with consumers, the food industry, and the government. Challenges relating to engaging the food industry and federal government through a state-led initiative were identified. New approaches to overcome this, such as forming clear "asks" to government and committing industry to "pledges" on reformulation were suggested. Stakeholder interviews and qualitative analysis have provided a range of important insights into barriers and enablers, many of which have already been used to strengthen intervention implementation. The evaluation of the VicSalt Partnership is ongoing and the program is expected to provide a wealth of lessons for state-led interventions to reduce salt intake in Australia and globally.

Salt consumption by Australian adults: a systematic review and meta-analysis

OBJECTIVE

Salt reduction is a public health priority because it is a leading contributor to the global burden of disease. As in Australia there is uncertainty about the current level of salt intake, we sought to estimate current levels.

STUDY DESIGN

Random effects meta-analysis of data from 31 published studies and one unpublished dataset that reported salt or sodium consumption by Australian adults on the basis of 24-hour urine collections or dietary questionnaires.

DATA SOURCES

MEDLINE (via Ovid) and EMBASE (to August 2016).

DATA SYNTHESIS

Thirty-one published studies and one unpublished dataset (1989-2015; 16 836 individuals) were identified. The mean weighted salt consumption estimated from 24-hour urine collections was 8.70 g/day (95% CI, 8.39-9.02 g/day); after adjusting for non-urinary salt excretion, the best estimate of salt intake in Australia is 9.6 g/day. The mean weighted intake was 10.1 g/day (95% CI, 9.68-10.5 g/day) for men and 7.34 g/day (95% CI, 6.98-7.70 g/day) for women. Mean weighted consumption was 6.49 g/day (95% CI, 5.94-7.03 g/day) when measured with diet diaries, 6.76 g/day (95% CI, 5.48-8.05 g/day) when assessed with food frequency questionnaires, and 6.73 g/day (95% CI, 6.34-7.11) when assessed by dietary recall. Salt intake had not decreased between 1989 and 2015 (R² = -0.02; P = 0.36).

CONCLUSION

Salt intake in Australian adults exceeds the WHO-recommended maximum of 5 g/day and does not appear to be declining. Measuring salt intake with methods based on self-reporting can substantially underestimate consumption. The data highlight the need for ongoing action to reduce salt consumption in Australia and robust monitoring of population salt intake.

NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4

The third UN High-Level Meeting on Non-Communicable Diseases (NCDs) on Sept 27, 2018, will review national and global progress towards the prevention and control of NCDs, and provide an opportunity to renew, reinforce, and enhance commitments to reduce their burden. NCD Countdown 2030 is an independent collaboration to inform policies that aim to reduce the worldwide burden of NCDs, and to ensure accountability towards this aim. In 2016, an estimated 40·5 million (71%) of the 56·9 million worldwide deaths were from NCDs. Of these, an estimated 1·7 million (4% of NCD deaths) occurred in people younger than 30 years of age, 15·2 million (38%) in people aged between 30 years and 70 years, and 23·6 million (58%) in people aged 70 years and older. An estimated 32·2 million NCD deaths (80%) were due to cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes, and another 8·3 million (20%) were from other NCDs. Women in 164 (88%) and men in 165 (89%) of 186 countries and territories had a higher probability of dying before 70 years of age from an NCD than from communicable, maternal, perinatal, and nutritional conditions combined. Globally, the lowest risks of NCD mortality in 2016 were seen in high-income countries in Asia-Pacific, western Europe, and Australasia, and in Canada. The highest risks of dying from NCDs were observed in low-income and middle-income countries, especially in sub-Saharan Africa, and, for men, in central Asia and eastern Europe. Sustainable Development Goal (SDG) target 3.4-a one-third reduction, relative to 2015 levels, in the probability of dying between 30 years and 70 years of age from cancers, cardiovascular diseases, chronic respiratory diseases, and diabetes by 2030-will be achieved in 35 countries (19%) for women, and 30 (16%) for men, if these countries maintain or surpass their 2010-2016 rate of decline in NCD mortality. Most of these are high-income countries with already-low NCD mortality, and countries in central and eastern Europe. An additional 50 (27%) countries for women and 35 (19%) for men are projected to achieve such a reduction in the subsequent decade, and thus, with slight acceleration of decline, could meet the 2030 target. 86 (46%) countries for women and 97 (52%) for men need implementation of policies that substantially increase the rates of decline. Mortality from the four NCDs included in SDG target 3.4 has stagnated or increased since 2010 among women in 15 (8%) countries and men in 24 (13%) countries. NCDs and age groups other than those included in the SDG target 3.4 are responsible for a higher risk of death in low-income and middle-income countries than in high-income countries. Substantial reduction of NCD mortality requires policies that considerably reduce tobacco and alcohol use and blood pressure, and equitable access to efficacious and high-quality preventive and curative care for acute and chronic NCDs.

Applications of systems modelling in obesity research

Obesity is a complex system problem involving a broad spectrum of policy, social, economic, cultural, environmental, behavioural, and biological factors and the complex interrelated, cross-sector, non-linear, dynamic relationships among them. Systems modelling is an innovative approach with the potential for advancing obesity research. This study examined the applications of systems modelling in obesity research published between 2000 and 2017, examined how the systems models were developed and used in obesity studies and discussed related gaps in current research. We focused on the applications of two main systems modelling approaches: system dynamics modelling and agent-based modelling. The past two decades have seen a growing body of systems modelling in obesity research. The research topics ranged from micro-level to macro-level energy-balance-related behaviours and policies (19 studies), population dynamics (five studies), policy effect simulations (eight studies), environmental (10 studies) and social influences (15 studies) and their effects on obesity rates. Overall, systems analysis in public health research is still in its early stages, with limitations linked to model validity, mixed findings and its actual use in guiding interventions. Challenges in theory and modelling practices need to be addressed to realize the full potential of systems modelling in future obesity research and interventions.

Estimating mean change in population salt intake using spot urine samples

Background

Spot urine samples are easier to collect than 24-h urine samples and have been used with estimating equations to derive the mean daily salt intake of a population. Whether equations using data from spot urine samples can also be used to estimate change in mean daily population salt intake over time is unknown. We compared estimates of change in mean daily population salt intake based upon 24-h urine collections with estimates derived using equations based on spot urine samples.

Methods

Paired and unpaired 24-h urine samples and spot urine samples were collected from individuals in two Australian populations, in 2011 and 2014. Estimates of change in daily mean population salt intake between 2011 and 2014 were obtained directly from the 24-h urine samples and by applying established estimating equations (Kawasaki, Tanaka, Mage, Toft, INTERSALT) to the data from spot urine samples. Differences between 2011 and 2014 were calculated using mixed models.

Results

A total of 1000 participants provided a 24-h urine sample and a spot urine sample in 2011, and 1012 did so in 2014 (paired samples n = 870; unpaired samples n = 1142). The participants were community-dwelling individuals living in the State of Victoria or the town of Lithgow in the State of New South Wales, Australia, with a mean age of 55 years in 2011. The mean (95% confidence interval) difference in population salt intake between 2011 and 2014 determined from the 24-h urine samples was -0.48g/day (-0.74 to -0.21; P < 0.001). The corresponding result estimated from the spot urine samples was -0.24 g/day (-0.42 to -0.06; P = 0.01) using the Tanaka equation, -0.42 g/day (-0.70 to -0.13; p = 0.004) using the Kawasaki equation, -0.51 g/day (-1.00 to -0.01; P = 0.046) using the Mage equation, -0.26 g/day (-0.42 to -0.10; P = 0.001) using the Toft equation, -0.20 g/day (-0.32 to -0.09; P = 0.001) using the INTERSALT equation and -0.27 g/day (-0.39 to -0.15; P < 0.001) using the INTERSALT equation with potassium. There was no evidence that the changes detected by the 24-h collections and estimating equations were different (all P > 0.058). Separate analysis of the unpaired and paired data showed that detection of change by the estimating equations was observed only in the paired data.

Conclusions

All the estimating equations based upon spot urine samples identified a similar change in daily salt intake to that detected by the 24-h urine samples. Methods based upon spot urine samples may provide an approach to measuring change in mean population salt intake, although further investigation in larger and more diverse population groups is required.

Effective approaches to address the global cardiovascular disease burden

PURPOSE OF REVIEW

Describe the global burden of cardiovascular disease (CVD), highlight barriers to evidence-based care and propose effective interventions based on identified barriers.

RECENT FINDINGS

The global burden of CVD is increasing worldwide. This trend is steeper in lower income countries, where CVD incidence and fatality remains high. Risk factor control, around the world, remains poor, especially in lower and middle-income countries. Barriers at the patient, healthcare provider and health system have been identified. The use of multifaceted interventions that target identified contextual barriers to care, including increasing awareness of CVD and related risk, improving health policy (i.e. taxation of tobacco), improving the availability and affordability of fixed-dose combined medications and task-shifting of healthcare responsibilities are potential solutions to improve the global burden of CVD.

SUMMARY

There is a need to address identified barriers using evidence-based and multifaceted interventions. Global initiatives, led by the World Heart Federation and the WHO, to facilitate the implementation of such interventions are underway.

Spot urine and 24-h diet recall estimates of dietary sodium intake from the 2008/09 New Zealand Adult Nutrition Survey: a comparison

BACKGROUND

We aimed to test the difference between estimates of dietary sodium intake using 24-h diet recall and spot urine collection in a large sample of New Zealand adults.

METHODS

We analysed spot urine results, 24-h diet recall, dietary habits questionnaire and anthropometry from a representative sample of 3312 adults aged 15 years and older who participated in the 2008/09 New Zealand Adult Nutrition Survey. Estimates of adult population sodium intake were derived from 24-h diet recall and spot urine sodium using a formula derived from analysis of INTERSALT data. Correlations, limits of agreement and mean difference were calculated for the total sample, and for population subgroups.

RESULTS

Estimated total population 24-h urinary sodium excretion (mean (95% CI)) from spot urine samples was 3035 mg (2990, 3079); 3612 mg (3549, 3674) for men and 2507 mg (2466, 2548) for women. Estimated mean usual daily sodium intake from 24-h diet recall data (excluding salt added at the table) was 2564 mg (2519, 2608); 2849 mg (2779, 2920) for men and 2304 mg (2258, 2350) for women. Correlations between estimates were poor, especially for men, and limits of agreement using Bland-Altman mean difference analysis were wide.

CONCLUSIONS

There is a poor agreement between estimates of individual sodium intake from spot urine collection and those from 24-hour diet recall. Although, both 24-hour dietary recall and estimated urinary excretion based on spot urine indicate mean population sodium intake is greater than 2 g, significant differences in mean intake by method deserve further investigation in relation to the gold standard, 24-hour urinary sodium excretion.

Equity impacts of price policies to promote healthy behaviours

Governments can use fiscal policies to regulate the prices and consumption of potentially unhealthy products. However, policies aimed at reducing consumption by increasing prices, for example by taxation, might impose an unfair financial burden on low-income households. We used data from household expenditure surveys to estimate patterns of expenditure on potentially unhealthy products by socioeconomic status, with a primary focus on low-income and middle-income countries. Price policies affect the consumption and expenditure of a larger number of high-income households than low-income households, and any resulting price increases tend to be financed disproportionately by high-income households. As a share of all household consumption, however, price increases are often a larger financial burden for low-income households than for high-income households, most consistently in the case of tobacco, depending on how much consumption decreases in response to increased prices. Large health benefits often accrue to individual low-income consumers because of their strong response to price changes. The potentially larger financial burden on low-income households created by taxation could be mitigated by a pro-poor use of the generated tax revenues.

Action to address the household economic burden of non-communicable diseases

The economic burden on households of non-communicable diseases (NCDs), including cardiovascular diseases, cancer, respiratory diseases, and diabetes, poses major challenges to global poverty alleviation efforts. For patients with NCDs, being uninsured is associated with 2-7-fold higher odds of catastrophic levels of out-of-pocket costs; however, the protection offered by health insurance is often incomplete. To enable coverage of the predictable and long-term costs of treatment, national programmes to extend financial protection should be based on schemes that entail compulsory enrolment or be financed through taxation. Priority should be given to eliminating financial barriers to the uptake of and adherence to interventions that are cost-effective and are designed to help the poor. In concert with programmes to strengthen national health systems and governance arrangements, comprehensive financial protection against the growing burden of NCDs is crucial in meeting the UN's Sustainable Development Goals.

Estimating population salt intake in India using spot urine samples

OBJECTIVE

To compare estimates of mean population salt intake in North and South India derived from spot urine samples versus 24-h urine collections.

METHODS

In a cross-sectional survey, participants were sampled from slum, urban and rural communities in North and in South India. Participants provided 24-h urine collections, and random morning spot urine samples. Salt intake was estimated from the spot urine samples using a series of established estimating equations. Salt intake data from the 24-h urine collections and spot urine equations were weighted to provide estimates of salt intake for Delhi and Haryana, and Andhra Pradesh.

RESULTS

A total of 957 individuals provided a complete 24-h urine collection and a spot urine sample. Weighted mean salt intake based on the 24-h urine collection, was 8.59 (95% confidence interval 7.73-9.45) and 9.46 g/day (8.95-9.96) in Delhi and Haryana, and Andhra Pradesh, respectively. Corresponding estimates based on the Tanaka equation [9.04 (8.63-9.45) and 9.79 g/day (9.62-9.96) for Delhi and Haryana, and Andhra Pradesh, respectively], the Mage equation [8.80 (7.67-9.94) and 10.19 g/day (95% CI 9.59-10.79)], the INTERSALT equation [7.99 (7.61-8.37) and 8.64 g/day (8.04-9.23)] and the INTERSALT equation with potassium [8.13 (7.74-8.52) and 8.81 g/day (8.16-9.46)] were all within 1 g/day of the estimate based upon 24-h collections. For the Toft equation, estimates were 1-2 g/day higher [9.94 (9.24-10.64) and 10.69 g/day (9.44-11.93)] and for the Kawasaki equation they were 3-4 g/day higher [12.14 (11.30-12.97) and 13.64 g/day (13.15-14.12)].

CONCLUSION

In urban and rural areas in North and South India, most spot urine-based equations provided reasonable estimates of mean population salt intake. Equations that did not provide good estimates may have failed because specimen collection was not aligned with the original method.

Evaluation of research on interventions aligned to WHO 'Best Buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Background

Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs).

Aim

To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs.

Methods

We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence.

Results

We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs.

Conclusions

We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

The association of estimated salt intake with blood pressure in a Viet Nam national survey

OBJECTIVE

To evaluate the association of salt consumption with blood pressure in Viet Nam, a developing country with a high level of salt consumption.

DESIGN AND SETTING

Analysis of a nationally representative sample of Vietnamese adults 25-65 years of age who were surveyed using the World Health Organization STEPwise approach to Surveillance protocol. Participants who reported acute illness, pregnancy, or current use of antihypertensive medications were excluded. Daily salt consumption was estimated from fasting mid-morning spot urine samples. Associations of salt consumption with systolic blood pressure and prevalent hypertension were assessed using adjusted linear and generalized linear models. Interaction terms were tested to assess differences by age, smoking, alcohol consumption, and rural/urban status.

RESULTS

The analysis included 2,333 participants (mean age: 37 years, 46% male, 33% urban). The average estimated salt consumption was 10g/day. No associations of salt consumption with blood pressure or prevalent hypertension were observed at a national scale in men or women. The associations did not differ in subgroups defined by age, smoking, or alcohol consumption; however, associations differed between urban and rural participants (p-value for interaction of urban/rural status with salt consumption, p = 0.02), suggesting that higher salt consumption may be associated with higher systolic blood pressure in urban residents but lower systolic blood pressure in rural residents.

CONCLUSIONS

Although there was no evidence of an association at a national level, associations of salt consumption with blood pressure differed between urban and rural residents in Viet Nam. The reasons for this differential association are not clear, and given the large rate of rural to urban migration experienced in Viet Nam, this topic warrants further investigation.

Hypouricemic Effects of Ganoderma applanatum in Hyperuricemia Mice through OAT1 and GLUT9

Ganoderma applanatum (G. applanatum) dispels wind to eliminate dampness and exhibited nephron- and liver-protective effects as noted in Chinese herbal classic literature; it might also affect hyperuricemia. Therefore, we examined the hypouricemia effects and mechanisms underlying G. applanatum on chemical-induced hyperuricemia in mice. Ethanol (GAE) and water (GAW) extracts were prepared by extracting G. applanatum in ethanol (GAE), followed by bathing the remains in water to yield GAW. GAE and GAW were administered orally at different doses to hyperuricemia mice, while allopurinol and benzbromarone served as positive controls. Both GAE and GAW showed remarkable hypouricemia activities, rendering a substantial decline in the SUA (serum uric acid) level in hyperuricemia control (P < 0.01). Moreover, the urine uric acid (UUA) levels were enhanced by GAE and GAW. In contrast to the evident renal toxicity of allopurinol, GAE and GAW did not show a distinct renal toxicity. Almost no suppressing effect was observed on the XOD activities. However, compared to the hyperuricemia control, OAT1 was elevated remarkably in mice drugged with GAE and GAW, while GLUT9 was significantly decreased. Similar to benzbromarone, GAE decreased the URAT1 protein levels significantly (P < 0.01), while GAW did not display a similar effect. GAE and GAW downregulated the level of CNT2 proteins in the gastrointestinal tract of hyperuricemia mice. Thus, G. applanatum produced outstanding hypouricemic effects, mediated by renal OAT1, GLUT9, and URAT1 and gastrointestinal CNT2 that might elevate urine uric secretions and decline in the absorption of purine in the gastrointestinal tracts. G. applanatum showed little negative influence on inner organs. By docking screening, four top-ranked compounds were identified that necessitated further investigation. Compounds: potassium oxonate, hypoxanthine, allopurinol, benzbromarone.

Socioeconomic and cultural impact of tobacco in India

Tobacco consumed either in the form of smoke or smokeless is hazardous to the human body. Death toll due to tobacco globally, has risen to about 6.4 million annually, and is on a constant increase. Since long, tobacco consumption has been attributed to a variety of factors including geographical variation, cultural factors and other associated variables. Earlier tobacco was considered as a taboo, but with advent of 21^st century and commercialization of tobacco it has been prevalent among males and females. Global adult tobacco survey (GATS) in India 2016-17 revealed that there has been drop of 34.1% tobacco consumers in India, mainly due to the increasing awareness and anti-tobacco campaigns and tobacco hazards warning on the packs. Analysing the changes in trends by healthcare professionals can prove to be a valuable tool in devising strategies to control and limit the morbidity and mortality caused due to tobacco consumption.

Identification of differences in health impact modelling of salt reduction

We examined whether specific input data and assumptions explain outcome differences in otherwise comparable health impact assessment models. Seven population health models estimating the impact of salt reduction on morbidity and mortality in western populations were compared on four sets of key features, their underlying assumptions and input data. Next, assumptions and input data were varied one by one in a default approach (the DYNAMO-HIA model) to examine how it influences the estimated health impact. Major differences in outcome were related to the size and shape of the dose-response relation between salt and blood pressure and blood pressure and disease. Modifying the effect sizes in the salt to health association resulted in the largest change in health impact estimates (33% lower), whereas other changes had less influence. Differences in health impact assessment model structure and input data may affect the health impact estimate. Therefore, clearly defined assumptions and transparent reporting for different models is crucial. However, the estimated impact of salt reduction was substantial in all of the models used, emphasizing the need for public health actions.

Mean population salt consumption in India: a systematic review

BACKGROUND

Member states of the WHO, including India, have adopted a target 30% reduction in mean population salt consumption by 2025 to prevent noncommunicable diseases. Our aim was to support this initiative by summarizing existing data that describe mean salt consumption in India.

METHOD

Electronic databases - MEDLINE via Ovid, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews - were searched up to November 2015 for studies that reported mean or median dietary salt intake in Indian adults aged 19 years and older. Random effects meta-analysis was used to obtain summary estimates of salt intake.

RESULTS

Of 1201 abstracts identified, 90 were reviewed in full text and 21 were included: 18 cross-sectional surveys (n = 225 024), two randomized trials (n = 255) and one case-control study (n = 270). Data were collected between 1986 and 2014, and reported mean salt consumption levels were between 5.22 and 42.30 g/day. With an extreme outlier excluded, overall mean weighted salt intake was 10.98 g/day (95% confidence interval 8.57-13.40). There was significant heterogeneity between the estimates for contributing studies (I = 99.97%) (P homogeneity ≤0.001), which was likely attributable to the different measurement methods used and the different populations studied. There was no evidence of a change in intake over time (P trend = 0.08).

CONCLUSION

The available data leave some uncertainty about exact mean salt consumption in India but there is little doubt that population salt consumption far exceeds the WHO-recommended maximum of 5 g per person per day.

Primordial and Primary Preventions of Thyroid Disease

BACKGROUND

Primordial and primary preventions of thyroid diseases are concerned with avoiding the appearance of risk factors, delaying the progression to overt disease, and minimizing the impact of illness.

SUMMARY

Using related key words, 446 articles related to primordial and primary, preventions of thyroid diseases published between 2001-2015 were evaluated, categorized and analyzed. Prevention and elimination of iodine deficiency are major steps that have been successfully achieved and maintained in many countries of the world in last 2 decades. Recent investigations related to the effect of cigarette smoking, alcohol consumption, and autoimmunity in the prevention of thyroid disorders have been reviewed.

CONCLUSIONS

The cornerstone for successful prevention of thyroid disease entails timely implementation of its primordial and primary preventions, which must be highly prioritized in related health strategies by health authorities.

Large-Scale Evaluation of Quality of Care in 6 Countries of Eastern Europe and Central Asia Using Clinical Performance and Value Vignettes

When providers in 6 different countries were asked how they would care for the same patient, there was wide variation within and between countries. Nevertheless, 11% of the physicians scored over 80%, suggesting good quality of care is possible even with resource constraints. Use of validated clinical vignettes, which can be applied affordably at scale, could help improve quality of services in low- and middle-income countries.

Background:

A significant determinant of population health outcomes is the quality of care provided for noncommunicable diseases, obstetric, and pediatric care. We present results on clinical practice quality in these areas as measured among nearly 4,000 providers working at more than 1,000 facilities in 6 Eastern European and Central Asian countries.

Methods:

This study was conducted between March 2011 and April 2013 in Albania, Armenia, Georgia, Kazakhstan, Kirov Province in Russia, and Tajikistan. Using a probability proportional-to-size sampling technique, based on number of hospital beds, we randomly selected within each country 42 hospitals and their associated primary health care clinics. Physicians and midwives within each clinical area of interest were randomly selected from each hospital and clinic and asked how they would care for simulated patients using Clinical Performance and Value (CPV) vignettes. Facility administrators were also asked to complete a facility survey to collect structural measures of quality. CPV vignettes were scored on a scale of 0% to 100% for each provider. We used descriptive statistics and t tests to identify significant differences in CPV scores between hospitals and clinics and rural vs. urban facilities, and ANOVA to identify significant differences in CPV scores across countries.

Results:

We found that quality of care, as concurrently measured by performance on CPV vignettes, was generally poor and widely variable within and between countries. Providers in Kirov Province, Russia, had the highest overall performance, with an average score of 70.8%, while providers in Albania and Tajikistan had the lowest average score, each at 50.8%. The CPV vignettes with the lowest scores were for multiple noncommunicable disease risk factors and birth asphyxia. A considerable proportion (11%) of providers performed well on the CPV vignettes, regardless of country, facility, or structural resources available to them.

Conclusions:

Countries of Eastern Europe and Central Asia are challenged by poor performance as measured by clinical care vignettes, but there is potential for provision of high-quality care by a sizable proportion of providers. Large-scale assessments of quality of care have been hampered by the lack of effective measurement tools that provide generalizable and reliable results across diverse economic, cultural, and social settings. The feasibility of quality measurement using CPV vignettes in these 6 countries and the ability to combine results with individual feedback could significantly enhance strategies to improve quality of care, and ultimately population health.

Cost and cost-effectiveness of a school-based education program to reduce salt intake in children and their families in China

Objective

The School-based Education Program to Reduce Salt Intake in Children and Their Families study was a cluster randomized control trial among grade five students in 28 primary schools and their families in Changzhi, China. It achieved a significant effect in lowering systolic blood pressure (SBP) in all family adults by 2.3 mmHg and in elderlies (aged > = 60 years) by 9.5 mmHg. The aim of this study was to assess the cost-effectiveness of this salt reduction program.

Methods

Costs of the intervention were assessed using an ingredients approach to identify resource use. A trial-based incremental cost-effectiveness ratio (ICER) was estimated based on the observed effectiveness in lowering SBP. A Markov model was used to estimate the long-term cost-effectiveness of the intervention, and then based on population data, extrapolated to a scenario where the program is scaled up nationwide. Findings were presented in terms of an incremental cost per quality-adjusted life year (QALY). The perspective was that of the health sector.

Results

The intervention cost Int$19.04 per family and yielded an ICER of Int$2.74 (90% CI: 1.17–12.30) per mmHg reduction of SBP in all participants (combining children and adult participants together) compared with control group. If scaled up nationwide for 10 years and assumed deterioration in treatment effect of 50% over this period, it would reach 165 million families and estimated to avert 42,720 acute myocardial infarction deaths and 107,512 stroke deaths in China. This would represent a gain of 635,816 QALYs over 10-year time frame, translating into Int$1,358 per QALY gained.

Conclusion

Based on WHO-CHOICE criteria, our analysis demonstrated that the proposed salt reduction strategy is highly cost-effective, and if scaled up nationwide, the benefits could be substantial.

Trial registration

ClinicalTrials.gov NCT01821144

[An analysis of breast cancer prevention in Brazil]

This research sets out to study the interrelationship between breast cancer prevention and the socioeconomic, demographic, behavioral, regional and health factors in determining the temporal frequency of tests for prevention by performing mammograms and breast exams in Brazil. Based on the information of the health supplement of the National Sampling Survey of Domiciles of 2008, a sample that includes only women over age 40 was created. To achieve the desired goal, the estimate of the ordered logit model is used to establish partial proportional odds, which revealed the main results as follows. Women with a good socioeconomic status, living in the more developed regions of the country, family structure including children, making a good self-assessment of health and having been diagnosed with some type of cancer in the past. This is the profile of women who are best at preventing breast cancer, both in relation to the demand for mammograms and to a greater demand for breast exam performed by a doctor or a nurse. The results also point to the fact that the majority of those interviewed had either had the tests in question within the previous year, or had never been exposed to such procedures.