State-level and community-level salt reduction initiatives: a systematic review of global programmes and their impact

Effectiveness of socioecological model-guided, smart device-based, and self-management-oriented lifestyle (3SLIFE) intervention on healthy lifestyles and metabolic syndrome risk in community residents: a cluster-randomized controlled trial

BACKGROUND

Mobile health (mHealth) lifestyle interventions have showed promise in improving healthy lifestyles and reducing metabolic syndrome (MetS) risk, yet most studies adopt isolated frameworks. The 3SLIFE model-integrating the socioecological model, smart devices, and self-management strategies-provides a holistic approach to sustained behavioral change. It considers environmental influences, empowers individuals in goal-setting and engagement, and leverages smart devices for monitoring and feedback. Despite its potential, evidence on this integrated approach remains scarce. This study applies 3SLIFE to community-dwelling adults, aiming to improve healthy lifestyles.

METHODS

In this parallel, cluster-randomized controlled trial, 20 communities in Southwestern China were randomly assigned 1:1 to either the intervention or control group. Participants in the intervention group received the 3SLIFE intervention for 6 months, while those in the control group received routine management. The healthy lifestyle score was calculated for each participant based on smoking, alcohol intake, physical activity, dietary habits, and overweight/obesity. The primary outcome was the change in the healthy lifestyle score at the end of the 6-month trial. Differences in the score between groups were estimated using generalized linear mixed-effects models in the intention-to-treat population at 3, 6, and 12 months of follow-up.

RESULTS

From April to July 2023, 383 community-dwelling adults (mean age: 57.64 ± 11.32 years; 42.30% male) were recruited-190 in the intervention group and 193 in the control group. After the 6-month intervention, the increase in the healthy lifestyle score was slightly higher in the intervention group (13.22 ± 3.30 to 13.40 ± 2.88) than in the control group (13.34 ± 3.10 to 12.79 ± 3.32), with a mean difference of 0.77 (95% CI, 0.17 to 1.38). A higher proportion in the intervention group reduced at least one unhealthy lifestyle compared to the control group (31.48% vs. 19.64%, P = 0.016). However, no significant difference in score change was observed between groups at 12-month follow-up.

CONCLUSIONS

This study provides evidence that the 3SLIFE intervention could modestly improve healthy lifestyles in a community-based population, but the effects were not sustained at the 12-month follow-up. A further refinement is needed to enhance the intervention's long-term effectiveness in promoting sustainable lifestyle changes and reduce MetS risk in communities.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2300070575.

Effect of population-based sodium reduction interventions on blood pressure: a systematic review and meta-analysis of randomized trials

This systematic review and meta-analysis included cluster randomized controlled trials that compared population-based sodium reduction interventions with usual care for blood pressure (BP) management. We searched PubMed, Cochrane Central Register of Controlled Trials, and IchuShi-Web and utilized a random-effects meta-analysis of the weighted mean difference (MD) in the comparison groups to collect data from the included trials. The primary outcome includes the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 36 articles with 66,803 participants to be eligible. The population-based sodium reduction interventions decreased office systolic BP (SBP) compared with usual care in 36 studies (MD: -2.64 mmHg [95% confidence interval: -3.48- to 1.80]), with evidence of heterogeneity. Office SBP exhibited significant benefits among in adults (30 studies) and adults/children (1 study) but not in children (5 studies). Furthermore, office diastolic BP demonstrated comparable benefits with office SBP. Sensitivity analyses by cluster type in adults revealed that the workplace-based intervention exerted a greater SBP-lowering effect than the clinic/facility-based intervention. However, no significant difference was observed in the SBP-lowering effect by intervention type. The interventions were more effective in hypertensive cohorts compared with non-hypertensive cohorts and in Asian cohorts compared with non-Asian cohorts. Additionally, the benefits for secondary outcomes, including salt (sodium chloride) intake, were similar to those for office BP. In conclusion, population-based sodium reduction interventions improved BP management compared with usual care. The benefits along with the observed heterogeneity should be considered prudent for implementation in public health and clinical practices. This meta-analysis considered 36 studies with 66,803 participants to be eligible. The population-based sodium reduction interventions decreased office BP compared with usual care in 36 studies, with evidence of heterogeneity. Sensitivity analyses by cluster type in adults (30 studies) revealed that community-, family-, school-, and workplace-based interventions reduced office SBP. Concerning intervention type, sodium reduction counseling, salt substitution, and monitoring decreased office SBP. Interventions were more effective in hypertensive cohorts compared with non-hypertensive cohorts. The benefits for salt intake (22 studies) and urinary sodium excretion (17 studies) were comparable to those for office BP. BP: blood pressure; DBP: diastolic blood pressure; MD: mean difference; Na: sodium; RR: risk ratio; SBP: systolic blood pressure.

Consumption of Sodium and Its Ratio to Potassium in Relation to All-Cause, Cause-Specific, and Premature Noncommunicable Disease Mortality in Middle-Aged Japanese Adults: A Prospective Cohort Study

BACKGROUND

Reducing premature noncommunicable disease (NCD) mortality is a global challenge. Sodium is thought to increase risk of NCDs via an effect of salt per se or high-salt foods on hypertension-induced cardiovascular disease (CVD) and gastrointestinal cancer. Further, relative risk of CVD is reportedly more closely associated with sodium-to-potassium ratio than that with sodium alone. However, few studies have investigated the effect of consumption of sodium or its ratio to consumption of potassium on risk of premature NCD death.

OBJECTIVES

We examined associations between intake of sodium and sodium-to-potassium ratio and risk of all-cause and cause-specific death, including premature NCD, in a Japanese prospective cohort study.

METHODS

During 1995-1998, a validated food frequency questionnaire was administered in 11 areas to 83,048 men and women aged 45-74 y. During 1,587,901 person-years of follow-up until the end of 2018, 17,727 all-cause deaths and 3555 premature NCD deaths were identified.

RESULTS

Higher sodium intake was significantly associated with increased risk of all-cause and premature NCD mortality, but not all NCD mortality, among men: multivariate hazards ratios for the highest compared with lowest quintiles (HR) were 1.11 (95% CI: 1.03, 1.20; P-trend < 0.01) for all-cause and 1.25 (95% CI: 1.06, 1.47; P-trend < 0.01) for premature NCD mortality. When intakes were expressed as ratio to potassium intake, these associations (HR of all-cause: 1.19, 95% CI: 1.11-1.27; P-trend < 0.01; HR of premature NCD: 1.27, 95% CI: 1.10, 1.46; P-trend < 0.01), including associations with cancers (HR: 1.18, 95% CI: 1.07, 1.31; P-trend = 0.02), were strengthened in men.

CONCLUSIONS

This prospective cohort study showed that both sodium intake and sodium-to-potassium ratio are associated with increased risk of all-cause and early NCD mortality in middle-aged men.

Associations between estimation of salt intake and salt-restriction spoons and hypertension status in patients with poorly controlled hypertension: a community-based study from Huzhou City, Eastern China

BACKGROUND

As the prevalence of hypertension increases in China, it is advised to use salt-restriction spoons (SRS) as a lifestyle modification. This study aimed to examine the associations between estimated salt consumption, SRS usage, and the hypertension status in individuals with poorly controlled hypertension.

METHODS

Data was collected in Huzhou City, Zhejiang Province, in 2021 using convenience sampling. The analysis involved ordinal logistic regression and restricted cubic splines to assess the relevant factors.

RESULTS

The study found that 73.34% of the 1215 patients had uncontrolled blood pressure (BP). Urinary excretion was assessed through the utilization of the Kawasaki, INTERSALT, and Tanaka formulas. The outcomes of these three methodologies revealed average daily sodium excretion values of 208.70 (65.65), 154.78 (33.91), and 162.61 (40.87) mmol, respectively. The prevalence of utilizing SRS was found to be 37.78% in this study. Despite the acknowledgment among SRS users of the potential hazards associated with excessive salt consumption, there exists a contradictory pattern of attitudes and behaviors concerning salt reduction. Among individuals with different levels of salt intake (quartiles 1-4, Q1 vs Q4), there was a positive association between limiting salt and hypertension status when controlling for other variables (Kawasaki adjusted OR = 0.58, 95% CI = 0.43-0.79; INTERSALT adjusted OR = 0.62, 95% CI = 0.41-0.92; Tanaka adjusted OR = 0.61, 95% CI = 0.45-0.92, p < 0.05). Our research also revealed that using or used SRS was a protective factor for blood BP control (adjusted OR = 0.79, 95% CI = 0.64-0.99, P < 0.05). The restricted cubic spline plots illustrated a monotonic upward relationship between estimated 24-h urinary Na and BP (P-overall association < 0.05; P-non-linear association > 0.05).

CONCLUSIONS

The use of dietary SRS could result in decrease in daily salt intake for BP control in patients with poorly controlled hypertension. To reduce the impact of high BP in China, additional studies are required to create interventions that can enhance the results for patients.

Outcomes of a state-wide salt reduction initiative in adults living in Victoria, Australia

PURPOSE

To assess any effects of a state-wide sodium reduction intervention on sodium intake, sources of dietary sodium and discretionary salt use at a population level.

METHODS

Data (24-h urinary sodium excretion, self-report survey, a 24-h dietary recall) were collected cross-sectionally at baseline (2016/2017) and follow-up (2020) from adults in Victoria, Australia. Intervention activities included consumer awareness advertising campaign, public debate generation via mass media, strengthening existing policy initiatives and supporting food innovation with industry.

RESULTS

There were 339 participants at baseline and 211 at follow-up, with 144 and 90 of participants completing a 24-h dietary recall, respectively. There was no difference in adjusted 24-h urinary sodium excretion between baseline and follow-up (134 vs 131 mmol/24 h; p = 0.260). There were no differences in the percentage of participants adding salt during cooking (63% vs 68%; p = 0.244), adding salt at the table (34% vs 37%; p = 0.400) or regularly taking action to control salt/sodium intake (22% vs 21%; p = 0.793). There were large differences in the quantity of dietary sodium sourced from retail stores (57% vs 77%, p < 0.001), and less sodium was sourced from foods at fresh food markets (13% vs 2%; p ≤ 0.001) at follow-up. No large differences were apparent for foods with different levels of processing or for food groups.

CONCLUSION

There was no clear population-level effect of the 4-year multi-component Victorian Salt Reduction Intervention on sodium intake with Victorian adults continuing to consume sodium above recommended levels. The findings indicate that more intensive and sustained efforts aiming at the retail and food industry with national level support are likely to be required to achieve a measurable improvement in sodium intake at a state level.

Effect of home cook interventions for salt reduction in China: cluster randomised controlled trial

OBJECTIVE

To determine the effects of salt reduction interventions designed for home cooks and family members.

DESIGN

Cluster randomised controlled trial.

SETTING

Six provinces in northern, central, and southern China from 15 October 2018 to 30 December 2019.

PARTICIPANTS

60 communities from six provinces (10 communities from each province) were randomised; each community comprised 26 people (two people from each of 13 families).

INTERVENTIONS

Participants in the intervention group received 12 month interventions, including supportive environment building for salt reduction, six education sessions on salt reduction, and salt intake monitoring by seven day weighed record of salt and salty condiments. The control group did not receive any of the interventions.

MAIN OUTCOME MEASURE

Difference between the two groups in change in salt intake measured by 24 hour urinary sodium during the 12 month follow-up.

RESULTS

1576 participants (775 (49.2%) men; mean age 55.8 (standard deviation 10.8) years) from 788 families (one home cook and one other adult in each family) completed the baseline assessment. After baseline assessment, 30 communities with 786 participants were allocated to the intervention group and 30 communities with 790 participants to the control group. During the trial, 157 (10%) participants were lost to follow-up, and the remaining 706 participants in the intervention group and 713 participants in the control group completed the follow-up assessment. During the 12 month follow-up, the urinary sodium excretion decreased from 4368.7 (standard deviation 1880.3) mg per 24 hours to 3977.0 (1688.8) mg per 24 hours in the intervention group and from 4418.7 (1973.7) mg per 24 hours to 4330.9 (1859.8) mg per 24 hours in the control group. Compared with the control group, adjusted mixed linear model analysis showed that the 24 hour urinary sodium excretion in the intervention group was reduced by 336.8 (95% confidence interval 127.9 to 545.7) mg per 24 hours (P=0.002); the systolic and diastolic blood pressures were reduced by 2.0 (0.4 to 3.5) (P=0.01) and 1.1 (0.1 to 2.0) mm Hg (P=0.03), respectively; and the knowledge, attitude, and behaviours in the intervention group improved significantly.

CONCLUSIONS

The community based salt reduction package targeting home cooks and family members was effective in lowering salt intake and blood pressure. This intervention has the potential to be widely applied in China and other countries where home cooking remains a major source of salt intake.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800016804.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia

OBJECTIVE

In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention.

DESIGN

Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models.

SETTING

Victoria, Australia.

PARTICIPANTS

Children aged 4-12 years.

RESULTS

Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged.

CONCLUSION

These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Identifying correlates of salt reduction practices among rural, middle-aged Muslim Indonesians with hypertension through structural equation modeling

Background: In 2016, the World Health Organization recommended salt reduction strategies. In most low- and middle-income countries, little is known about what causes people to reduce their salt intake. Aim: In rural West Java, Indonesia, we conducted a cross-sectional survey to describe self-reported salt reduction practices among middle-aged Muslims with hypertension (n = 447) and to identify correlates of salt reduction. Methods: We developed a questionnaire with Likert scales to measure self-reported frequency of efforts to reduce salt intake, and degree of agreement/disagreement with 51 statements about variables hypothesized to influence salt reduction practices. We compared groups using t-tests and one-way ANOVAs. Through one-factor confirmatory factor analysis and structural equation modeling, we identified correlates of salt reduction practices. Results: About 45% of participants reported regularly reducing their salt intake; only 12.8% reported never attempting. Men reported higher social barriers, while women reported higher family support and spiritual support. Overall, we found that participants' frequency of effort to reduce their salt intake was associated with a constellation of six correlates. Salt reduction practices were directly positively associated with prior health/illness experiences (β = 0.25), and by seeking health information (β = 0.24). Seeking health information was in turn positively associated with prior health/illness experiences (β = 0.34), receiving support from health professionals (β = 0.23) and Islamic spiritual practice (β = 0.24). Salt reduction practices were negatively associated with environmental barriers to healthful eating practices (β = -0.14). Conclusion: In this population, reinforcing positive correlates identified in this study and mitigating against negative correlates may foster salt reduction practices.

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18-65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (-8% (95%CI -12, -3)) and that their child added salt at the table (-5% (95% -9, -0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact.

Sodium Reduction in Restaurant Food: A Randomized Controlled Trial in China

Restaurant food is one of the important sources of sodium intake in China. We aimed to determine whether a restaurant-based comprehensive intervention program may induce lower sodium content in restaurant food. A randomized controlled trial was implemented between 2019 and 2020 in 192 restaurants in China. After baseline assessment, the restaurants were randomly assigned to either an intervention or a control group (1:1). Comprehensive activities designed for intervention restaurants were conducted for one year. The primary outcome was the difference in change of sodium content estimated by the mean values of five best-selling dishes for each restaurant, from baseline to the end of the trial between groups. In total, 66 control restaurants and 80 intervention restaurants completed the follow-up assessment. The average sodium content of dishes at baseline was 540.9 ± 176.8 mg/100 g in control and 551.9 ± 149.0 mg/100 g in intervention restaurants. The mean effect of intervention after adjusting for confounding factors was -43.63 mg/100 g (95% CI: from -92.94 to 5.66, p = 0.08), representing an 8% reduction in sodium content. The restaurant-based intervention led to a modest but not significant reduction in the sodium content of restaurant food. There is great urgency for implementing effective and sustainable salt reduction programs, due to the rapid increase in the consumption of restaurant food in China.

Strategic Sodium Reduction Initiative Reduces Sodium in Meals Served at Older Adult Congregate Meal Program Sites

Excessive sodium consumption is a public health issue and congregate meal programs provide a unique opportunity to reduce sodium served to a large, at-risk population. A Sodium Reduction Initiative (SRI) was implemented in a congregate meal program that serves over 3,000 older adults. Nutrient analyses conducted at baseline and post-intervention were used to calculate average sodium reduction and the number of low sodium foods; targeted foods were categorized by strategy. Customer satisfaction surveys were collected at baseline and 3- and 6-months post-intervention. Kruskal Wallis and analysis of variance were used to compare sodium reduction differences. Chi-square analysis determined associations among strategies. The SRI impacted 55 foods, low sodium foods increased by 22%, and the average sodium per menu cycle was reduced by 21%. Replacement with a lower sodium food was the most frequently used strategy and had the largest sodium reduction. Sauces and main entrees were most frequently impacted, and thirteen ingredients accounted for 75% of all reduced-sodium foods. Over 50% of the 1,424 survey respondents consumed the reduced-sodium foods and food satisfaction remained stable from baseline to post-intervention. Congregate meals programs that target commonly used foods and key ingredients can significantly reduce sodium served to older adults.

A Systematic Review of Salt Reduction Initiatives Around the World: A Midterm Evaluation of Progress Towards the 2025 Global Non-Communicable Diseases Salt Reduction Target

In 2013, the WHO recommended that all member states aim to reduce population salt intake by 30% by 2025. The year 2019 represents the midpoint, making it a critical time to assess countries' progress towards this target. This review aims to identify all national salt reduction initiatives around the world in 2019, and to quantify countries' progress in achieving the salt reduction target. Relevant data were identified through searches of peer-reviewed and gray literature, supplemented with responses from prefilled country questionnaires sent to known country leads of salt reduction or salt champions, WHO regional representatives, and international experts to request further information. Core characteristics of each country's strategy, including evaluations of program impact, were extracted and summarized. A total of 96 national salt reduction initiatives were identified, representing a 28% increase in the number reported in 2014. About 90% of the initiatives were multifaceted in approach, and 60% had a regulatory component. Approaches include interventions in settings (n= 74), food reformulation (n = 68), consumer education (n = 50), front-of-pack labeling (n = 48), and salt taxation (n = 5). Since 2014, there has been an increase in the number of countries implementing each of the approaches, except consumer education. Data on program impact were limited. There were 3 countries that reported a substantial decrease (>2 g/day), 9 that reported a moderate decrease (1-2 g/day), and 5 that reported a slight decrease (<1 g/day) in the mean salt intake over time, but none have yet met the targeted 30% relative reduction in salt intake from baseline. In summary, there has been an increase in the number of salt reduction initiatives around the world since 2014. More countries are now opting for structural or regulatory approaches. However, efforts must be urgently accelerated and replicated in other countries and more rigorous monitoring and evaluation of strategies is needed to achieve the salt reduction target.

A Review Study of a Green Diet and Healthy Ageing

Nowadays people are living longer, and there has been a substantial growth in the global elderly population in the past decades. While life expectancy is increasing, there are growing concerns towards the heavy financial and social burdens related to chronic diseases among the elderly. These have been critical health care issues, and healthy ageing is considered a top priority in public health. Diet and eating habits are crucial factors contributing to healthy ageing. These important aspects have attracted much attention in health research, particularly in consideration of the causes and management of chronic conditions which affect most elder adults in the world. Recently, a growing number of investigations have reported significant findings on the association of reduction in the risks of chronic non-communicable diseases with plant-based diets. Meanwhile, there have been worldwide initiatives and programmes implemented for reduction of salt intake. A green diet, which emphasises the consumption of a diet rich in plant foods with minimal portions of red or processed meat and reduced salt intake, is advocated with due consideration to the importance of sustainable environment and healthy ageing. This paper highlights a brief review of the recent advance of knowledge in diet and health, its effects on the elderly and the significance of a green diet on healthy ageing. Implications for a green diet and recommendations for future research are also discussed.

An evaluation of the Victorian Salt Reduction Partnership's advocacy strategy for policy change

BACKGROUND

Public health advocacy strategies facilitate policy change by bringing key health issues to the forefront of public and political discourse, influencing decision-makers and public opinion, and increasing policy demand. The Victorian Salt Reduction Partnership (VSRP) was established in 2014 in response to inadequate government action to improve population diets in Australia. This study aimed to evaluate the success of the VSRP's advocacy strategy in achieving policy change.

METHODS

Documentation of VSRP activities and outputs were collected, and semi-structured interviews conducted as part of a comprehensive process evaluation. For this study, the Kotter Plus 10-step public health advocacy evaluation framework was used to guide data extraction, analysis, and synthesis.

RESULTS

A sense of urgency for salt reduction was generated by producing evidence and outlining the potential impact of a state-based salt reduction programme. This enabled the creation of a coalition with diverse skills and expertise, which facilitated the development of an innovative and collaborative advocacy action plan. A clear change vision was established, but communication of the vision to decision-makers was lacking, which reduced the impact of the programme as decision-makers were not provided with a clear incentive for policy change. As a result, while programme outputs were achieved, these did not translate to achieving broader strategic goals during a limited-term intervention in a political climate unconcerned with salt.

CONCLUSIONS

The Kotter Plus 10-step framework was a useful tool for evaluating the success of the VSRP advocacy strategy. The framework enabled the identification of key strengths, including the creation of the guiding coalition, and areas where efforts could be improved in future similar strategies, such as effective communication within partnerships and to decision-makers, to better influence policy and improve public health impact.

Stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership: a qualitative study

BACKGROUND

Interventions to reduce population salt intake are feasible and cost-effective. The Victorian Salt Reduction Partnership implemented a complex, multi-faceted salt reduction intervention between 2014 and 2020 in the Australian state of Victoria. This study aimed to understand stakeholder perspectives on the effectiveness of the Victorian Salt Reduction Partnership.

METHODS

Semi-structured interviews were conducted with Partnership and food industry stakeholders. The Consolidated Framework for Implementation Research was adapted for the Partnership intervention and used to guide the qualitative analysis.

RESULTS

Fourteen Partnership and seven food industry stakeholders were interviewed. The Partnership was viewed as essential for intervention planning and decision-making and an enabler for intervention delivery. The goals of capacity building and collaborative action were perceived to have been achieved. The implementation team executed intended intervention activities and outputs, with some adaptations to strategy. Barriers and enablers to implementation were identified by interviewees, such as compatibility of individual, organisational and Partnership values and building positive relationships between the Partnership and food industry, respectively. Legal, political, social, environmental, technological and economic factors affecting intervention design, delivery and outcomes were identified.

CONCLUSIONS

Establishing a Partnership with diverse skills and experience facilitated collaborative action, capacity building and execution of the intervention. Monitoring and evaluating implementation informed strategy adaptations, which allowed optimisation of Partnership strategy. The importance of developing strong communication networks between strategic and implementation-levels was a key lesson.

Low awareness of high sodium intake among older Chinese people

Awareness is one of the first steps in a lifestyle modification process. Since older adults are at a higher risk of hypertension, maintaining low sodium intake is of utmost importance. Yet, it is uncertain if older adults have an awareness of their sodium intake. This study aimed to explore self-perceived sodium intake among older Chinese people and compare it with various measures of sodium intake. A cross-sectional study was conducted in Hong Kong in 2015. Data were collected from 24-h urinary sodium excretion (UNa24) measurements, dietary sodium intake by 24-h diet recalls and self-perceived salt intake levels among the older Hong Kong population. Kappa statistics and a paired t-test were used to compare the different measures. Fifty-nine participants provided complete 24-h urine samples. The mean (±SD) UNa24 of participants was 2846 ± 1253 mg, of which 74.6% exceeded the recommended daily sodium intake. About 87.8% of participants with UNa24 values >2000 mg perceived their sodium intake as too little or just right. The kappa statistic between UNa24 and self-perception was insignificantly different from zero (κ = -0.003, p-value = 0.909). The UNa24 estimates were significantly higher than those estimated from the 24-h diet recalls by 1203 mg (p-value <0.001). The findings imply that the low awareness of excessive sodium intake should be raised among older people to promote a healthy intake of sodium.

From Salt to Stroke-Evaluation of a Media Campaign for Sodium Reduction in Philadelphia

Excess dietary sodium contributes to the burden of chronic disease, including cardiovascular disease and stroke. Media-based health education campaigns are one strategy to raise awareness among populations at greater risk for stroke, including African Americans. During 2014–2015, the Philadelphia Department of Public Health conducted a health education campaign using radio, print news, and transit ads, to promote awareness of the link between dietary sodium, hypertension and stroke, and encourage reduced consumption of high sodium foods. Using a repeated cross-sectional design, street intercept surveys were conducted with ~400 Philadelphia residents representing the campaign's priority audience (African Americans ages 35–55) before and 6–13 weeks after the campaign, to evaluate both process (campaign exposure) and impact (recall of key health messages). Thirty percent of post-campaign respondents reported familiarity with one of the most engaging radio spots, and 17% provided accurate unaided recall of its key content, with greater recall among older respondents and frequent radio listeners. Forty-one percent of post-campaign respondents named stroke as a consequence of excess salt consumption, compared to only 17% of pre-campaign respondents, with greater awareness of the salt-stroke connection among those accurately recalling the radio spot from the campaign. Results suggest that priority populations for sodium reduction can be effectively reached through radio and transit campaigns. From a pragmatic perspective, street intercept surveys may offer one low resource strategy for evaluating public health education campaigns conducted by local health departments, especially among urban populations.

Sodium Reduction: How Big Might the Risks and Benefits Be?

Cardiovascular diseases are the leading cause of death worldwide and raised blood pressure is the leading risk for these conditions. Excess sodium intake clearly elevates blood pressure though the association of sodium intake with cardiovascular outcomes has been disputed. Nonetheless, it was estimated that in 2017 excess dietary sodium caused between 1.4 and 5.4 million deaths. Key underlying assumptions for those estimates were that the association between sodium intake and cardiovascular disease is direct and linear, and that a daily consumption level of 2.0 g of sodium minimised risk. Recent data indicating that reported U-shaped associations of sodium with risk are the result of confounding provide strong support for the first assumption. Cardiovascular risks may, however, continue to decline below intake levels of 2.0 g per day. Further, because excess sodium intake appears to drive a progressive rise in blood pressure with age, the magnitude of the disease burden avoidable by sodium reduction may have been under-estimated. Regardless, health benefits will only be achieved if safe, effective and scalable interventions can be defined and none have been identified to date. Salt substitution, which switches regular salt for a reduced-sodium, added-potassium alternative offers a significant opportunity. Falls in blood pressure with salt substitution are comparable to single-drug therapy and salt substitutes are low cost, simple to use, well-tolerated and could be applied community-wide. Data that prove clinical benefits and exclude risks will be required to support widespread use. An ongoing large-scale randomised trial of the effects of salt substitution on stroke, major cardiovascular events and death will complete soon and define the role of salt substitutes in public health.

Primary prevention of ischaemic heart disease: populations, individuals, and health professionals

Ischaemic heart disease has a multifactorial aetiology and can be prevented from developing in populations primordially, and in individuals at high risk by primary prevention. The primordial approach focuses on social determinants of health in populations: political, economic, and social factors, principally unplanned urbanisation, illiteracy, poverty, and working and living conditions. Implementation of the UN Sustainable Development Goals can lead to major improvements in cardiovascular health, and adequate health-care financing and universal health care are important for achieving these goals. Population-level interventions should focus on tobacco control, promotion of healthy foods (fruits, vegetables, legumes, and nuts), curbing unhealthy foods (saturated fats, trans fats, refined carbohydrates, excessive salt, and alcohol), promotion of physical activity in everyday living, and control of ambient and indoor pollution. At the individual level, identification of people at high multifactorial risk and guideline-driven management of hypertension, LDL cholesterol, and diabetes is required. Strategies to improve adherence to healthy lifestyles and drug therapies are essential and can be implemented at health system, health care, and patient levels with use of education, technology, and personalised approaches. Improving quality of medical education with a focus on ischaemic heart disease prevention for physicians, nurses, allied health workers, and the public is required.

The Evaluation of IDEAL-REACH Program to Improve Nutrition among Asian American Community Members in the Philadelphia Metropolitan Area

Objective Asian Americans' food purchasing, cooking, and eating patterns are not well understood. Greater insight into these behaviors is urgently needed to guide public health interventions of dietary behaviors in this population. The present study aims to examine the effects of a community-level intervention on food purchasing and preparation, nutrition knowledge, and health awareness in Asian Americans. Methods From 2015 to 2017, we conducted the Improving Diets with an Ecological Approach for Lifestyle (IDEAL-REACH) intervention to increase access to healthy food or beverage options for the Asian-American population in the Philadelphia metropolitan area. Participants (1110 at pre- and 1098 at post-assessment) were recruited from 31 community-based organizations (CBOs). We assessed Asian Americans' dietary behaviors, nutrition knowledge, and awareness of heart health. Results The results of pre-post intervention comparisons showed that the IDEAL-REACH intervention was successful in promoting whole grains consumption, reducing sodium consumption, and raising knowledge and awareness related to nutrition and heart health. Conclusions To our knowledge, this is one of the first initiatives in the U.S. to engage CBOs to promote healthier dietary behaviors. The findings show that CBOs serve as a powerful platform for community-level interventions to improve healthy nutrition behaviors in Asian-American communities.

The Science of Salt: A global review on changes in sodium levels in foods

This review aims to summarize and synthesize studies reporting on changes in sodium levels in packaged food products, restaurant foods, and hospital or school meals, as a result of salt reduction interventions. Studies were extracted from those published in the Science of Salt Weekly between June 2013 and February 2018. Twenty-four studies were identified: 17 assessed the changes in packaged foods, four in restaurant foods, two in hospital or school meals, and one in both packaged and restaurant foods. Three types of interventions were evaluated as part of the studies: voluntary reductions (including targets), labeling, and interventions in institutional settings. Decreases in sodium were observed in all studies (n = 8) that included the same packaged foods matched at two time points, and in the studies carried out in hospitals and schools. However, there was little to no change in mean sodium levels in restaurant foods. The pooled analysis of change in sodium levels in packaged foods showed a decrease in sodium in unmatched food products (-36 mg/100 g, 95% CI -51 to -20 mg/100 g) and in five food categories-breakfast cereals, breads, processed meats, crisps and snacks, and soups. Twenty-two of the 24 studies were from high-income countries, limiting the applicability of the findings to lower resource settings.

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.

Food Consumption, Knowledge, Attitudes, and Practices Related to Salt in Urban Areas in Five Sub-Saharan African Countries

High salt intake is a major risk factor of hypertension and cardiovascular disease. Improving knowledge, attitudes, and practices (KAP) related to salt intake in the general population is a key component of salt reduction strategies. The objective of this study was to describe and compare the KAP of adults related to salt in urban areas of five countries in sub-Saharan Africa. The survey included 588 participants aged 25 to 65 years who were selected using convenience samples in the urban areas of Benin, Guinea, Kenya, Mozambique, and Seychelles. Socio-demographic and food consumption were assessed using a structured closed-ended questionnaire administered by survey officers. Height, weight, and blood pressure were measured. Food consumption varied largely between countries. Processed foods high in salt, such as processed meat, cheese, pizzas, and savory snacks were consumed rather infrequently in all the countries, but salt-rich foods, such as soups or bread and salty condiments, were consumed frequently in all countries. The majority of the participants knew that high salt intake can cause health problems (85%) and thought that it is important to limit salt intake (91%). However, slightly over half (56%) of the respondents regularly tried to limit their salt intake while only 8% of the respondents thought that they consumed too much salt. Salt and salty condiments were added most of the time during cooking (92% and 64%, respectively) but rarely at the table (11%). These findings support the need for education campaigns to reduce salt added during cooking and for strategies to reduce salt content in selected manufactured foods in the region.

Process evaluation of Samoa's national salt reduction strategy (MASIMA): what interventions can be successfully replicated in lower-income countries?

BACKGROUND

Evidence for recommended interventions to reduce population salt intake come from high-income countries, but it is unknown if these can be successfully replicated in low- and middle-income countries. This process evaluation investigated the reach, dose/adoption, fidelity, cost, and context of a national salt reduction program of interventions in Samoa.

METHODS

Monitoring and Action on Salt in Samoa (MASIMA) was a pre- and post-intervention study of a government-led strategy to lower population salt intake comprising awareness campaigns, community mobilization and policy and environmental changes. Data relating to the five process evaluation dimensions were collected from routinely collected data, a post-intervention survey and stakeholder interviews. Chi-squared tests assessed differences in quantitative survey responses among groups. Thematic analysis of qualitative interview responses was undertaken and triangulated with the quantitative data.

RESULTS

Awareness campaigns, school nutrition standards, and community mobilization interventions were implemented with moderate reach and fidelity. Higher than expected costs of campaigns and limited opportunity (one-off) to mobilize community leaders to disseminate salt reduction messages were key implementation challenges, which meant intervention dose was low. Environmental-level initiatives including engagement with the food industry to voluntary reduce salt in foods and the introduction of salt-related regulations were more challenging to implement within 18-months, particularly given the delay in the passing of the Food Act which provides for enforcement of regulations. Contextual factors that hindered the interventions' mechanism of effect include the food culture, higher cost, and lower availability of healthy low-salt foods relative to unhealthy foods and salty taste preference.

CONCLUSION

Although individual and community-based interventions helped increase awareness about the importance of salt reduction in Samoa, legislative backing was needed to alter the food environment to achieve population reduction in salt intake. It was not possible to engage the food industry to lower salt in foods through a voluntary approach in Samoa's current context, although such initiatives were successful in some high-income countries. Future individual and environmental-level interventions to reduce salt intake need to address the contextual influences of food choices. In Samoa, this means salt reduction strategies need to ensure consuming lower salt is affordable, widely available, and perceived as flavorsome.

Protocol for the Process Evaluation of a Complex, Statewide Intervention to Reduce Salt Intake in Victoria, Australia

Systematic reviews of trials consistently demonstrate that reducing salt intake lowers blood pressure. However, there is limited evidence on how interventions function in the real world to achieve sustained population-wide salt reduction. Process evaluations are crucial for understanding how and why an intervention resulted in its observed effect in that setting, particularly for complex interventions. This project presents the detailed protocol for a process evaluation of a statewide strategy to lower salt intake in Victoria, Australia. We describe the pragmatic methods used to collect and analyse data on six process evaluation dimensions: reach, dose or adoption, fidelity, effectiveness, context and cost, informed by Linnan and Steckler's framework and RE-AIM. Data collection methods include routinely collected administrative data; surveys of processed foods, the population, food industry and organizations; targeted campaign evaluation and semi-structured interviews. Quantitative and qualitative data will be triangulated to provide validation or context for one another. This process evaluation will contribute new knowledge about what components of the intervention are important to salt reduction strategies and how the interventions cause reduced salt intake, to inform the transferability of the program to other Australian states and territories. This protocol can be adapted for other population-based, complex, disease prevention interventions.

The technical report on sodium intake and cardiovascular disease in low- and middle-income countries by the joint working group of the World Heart Federation, the European Society of Hypertension and the European Public Health Association

Ingestion of sodium is essential to health, but excess sodium intake is a risk factor for hypertension and cardiovascular disease. Defining an optimal range of sodium intake in populations has been challenging and controversial. Clinical trials evaluating the effect of sodium reduction on blood pressure have shown blood pressure lowering effects down to sodium intake of less than 1.5 g/day. Findings from these blood pressure trials form the basis for current guideline recommendations to reduce sodium intake to less than 2.3 g/day. However, these clinical trials employed interventions that are not feasible for population-wide implementation (i.e. feeding studies or intensive behavioural interventions), particularly in low and middle-income countries. Prospective cohort studies have identified the optimal range of sodium intake to reside in the moderate range (3-5 g/day), where the risk of cardiovascular disease and death is lowest. Therefore, there is consistent evidence from clinical trials and observational studies to support reducing sodium intake to less than 5 g/day in populations, but inconsistent evidence for further reductions below a moderate intake range (3-5 g/day). Unfortunately, there are no large randomized controlled trials comparing low sodium intake (< 3 g/day) to moderate sodium intake (3-5 g/day) in general populations to determine the net clinical effects of low sodium intake. Until such trials are completed, it is likely that controversy about optimal sodium intake range will continue. This working group calls for the completion of large definitive clinical trials to clarify the range of sodium intake for optimal cardiovascular health within the moderate to low intake range. We support interventions to reduce sodium intake in populations who consume high sodium intake (> 5 g/day), which should be embedded within an overall healthy dietary pattern.

Evaluation of a Healthy Chinese Take-Out Sodium-Reduction Initiative in Philadelphia Low-Income Communities and Neighborhoods

OBJECTIVES

Sodium reduction in restaurant foods is important because 77% of sodium in the United States is consumed by eating prepared and restaurant foods. We evaluated a sodium-reduction intervention, Healthy Chinese Take-Out Initiative, among Chinese take-out restaurants in low-income neighborhoods in Philadelphia, Pennsylvania. Our objectives were to (1) analyze changes in the sodium content of food samples and (2) collect data on changes in chefs' and owners' knowledge about the health risks of sodium overconsumption, perceptions of the need for sodium reduction, self-efficacy for lowering sodium use, and perceptions of training needs for sodium-reduction strategies.

METHODS

The initiative trained chefs from 206 Chinese take-out restaurants on strategies to reduce sodium in prepared dishes. We analyzed changes in the sodium content of the 3 most frequently ordered dishes-shrimp and broccoli, chicken lo mein, and General Tso's chicken-from baseline (July-September 2012) to 36 months after baseline (July-September 2015) among 40 restaurants. We conducted a survey to examine the changes in chefs' and owners' knowledge, perceptions, and self-efficacy of sodium reduction. We used multilevel analysis and repeated-measures analysis of variance to examine effects of the intervention on various outcomes.

RESULTS

We found significant reductions in the sodium content of all 3 dishes 36 months after a low-sodium cooking training intervention (coefficients range, -1.06 to -1.69, P < .001 for all). Mean knowledge (range, 9.2-11.1), perceptions (range, 4.6-6.0), and self-efficacy (range, 4.2-5.9) ( P < .001 for all) of sodium reduction improved significantly from baseline (August 2012) to posttraining (also August 2012), but perceptions of the need for sodium reduction and self-efficacy for lowering sodium use returned to baseline levels 36 months later (August 2015).

CONCLUSIONS

The intervention was a useful population health approach that led to engaging restaurants in sodium-reduction practices. Local public health agencies and professionals could partner with independent restaurants to introduce environmental changes that can affect population health on a broad scale, particularly for vulnerable populations.

The Sodium Content of Processed Foods in South Africa during the Introduction of Mandatory Sodium Limits

Background: In June 2016, the Republic of South Africa introduced legislation for mandatory limits for the upper sodium content permitted in a wide range of processed foods. We assessed the sodium levels of packaged foods in South Africa during the one-year period leading up to the mandatory implementation date of the legislation. Methods: Data on the nutritional composition of packaged foods was obtained from nutrition information panels on food labels through both in-store surveys and crowdsourcing by users of the HealthyFood Switch mobile phone app between June 2015 and August 2016. Summary sodium levels were calculated for 15 food categories, including the 13 categories covered by the sodium legislation. The percentage of foods that met the government’s 2016 sodium limits was also calculated. Results: 11,065 processed food items were included in the analyses; 1851 of these were subject to the sodium legislation. Overall, 67% of targeted foods had a sodium level at or below the legislated limit. Categories with the lowest percentage of foods that met legislated limits were bread (27%), potato crisps (41%), salt and vinegar flavoured snacks (42%), and raw processed sausages (45%). About half (49%) of targeted foods not meeting the legislated limits were less than 25% above the maximum sodium level. Conclusion: Sodium levels in two-thirds of foods covered by the South African sodium legislation were at or below the permitted upper levels at the mandatory implementation date of the legislation and many more were close to the limit. The South African food industry has an excellent opportunity to rapidly meet the legislated requirements.

Review of behaviour change interventions to reduce population salt intake

Background

Excess salt intake is a major cause of raised blood pressure—the leading risk factor for death and disability worldwide. Although behaviour change interventions such as awareness campaigns and health education programs are implemented to reduce salt intake, their effectiveness is unclear. This global systematic review investigates the impact of population-level behaviour change interventions that aim to reduce salt intake.

Methods

A search for published and grey literature was conducted using PubMed, Cochrane Library, Embase, Web of Science, Sage, Scopus, OpenGrey, Google Scholar and other relevant organizations’ websites. Studies were included if 1) published between 2005 and 2015; 2) the education or awareness-raising interventions were aimed at the population or sub-population and 3) salt intake and/or salt-related behaviours were outcome measures. Study and intervention characteristics were extracted for the descriptive synthesis and study quality was assessed.

Results

Twenty two studies involving 41,448 participants were included. Most were conducted in high income countries (n = 16), targeting adults (n = 21) in the general population (n = 16). Behaviour change interventions were categorised as health education interventions (n = 14), public awareness campaigns (n = 4) and multi-component interventions (including both health education and awareness campaigns, n = 4). 19 of the 22 studies demonstrated significant reductions in estimated salt intake and/or improvement in salt-related behaviours. All studies showed high risk of bias in one or more domains. Of the 10 higher quality studies, 5 found a significant effect on salt intake or salt behaviours based on the more objective outcome assessment method.

Conclusion

Based on moderate quality of evidence, population-level behaviour change interventions can improve salt-related behaviours and/or reduce salt intake. However, closer analysis of higher quality studies show inconsistent evidence of the effectiveness and limited effect sizes suggest the implementation of education and awareness-raising interventions alone are unlikely to be adequate in reducing population salt intake to the recommended levels. A framework which guides rigorous research and evaluation of population-level interventions in real-world settings would help understand and support more effective implementation of interventions to reduce salt intake.

Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations

OBJECTIVE

 To quantify the cost effectiveness of a government policy combining targeted industry agreements and public education to reduce sodium intake in 183 countries worldwide.

DESIGN

 Global modeling study.

SETTING

 183 countries.

POPULATION

 Full adult population in each country.

INTERVENTION

 A "soft regulation" national policy that combines targeted industry agreements, government monitoring, and public education to reduce population sodium intake, modeled on the recent successful UK program. To account for heterogeneity in efficacy across countries, a range of scenarios were evaluated, including 10%, 30%, 0.5 g/day, and 1.5 g/day sodium reductions achieved over 10 years. We characterized global sodium intakes, blood pressure levels, effects of sodium on blood pressure and of blood pressure on cardiovascular disease, and cardiovascular disease rates in 2010, each by age and sex, in 183 countries. Country specific costs of a sodium reduction policy were estimated using the World Health Organization Noncommunicable Disease Costing Tool. Country specific impacts on mortality and disability adjusted life years (DALYs) were modeled using comparative risk assessment. We only evaluated program costs, without incorporating potential healthcare savings from prevented events, to provide conservative estimates of cost effectiveness MAIN OUTCOME MEASURE:  Cost effectiveness ratio, evaluated as purchasing power parity adjusted international dollars (equivalent to the country specific purchasing power of US$) per DALY saved over 10 years.

RESULTS

 Worldwide, a 10% reduction in sodium consumption over 10 years within each country was projected to avert approximately 5.8 million DALYs/year related to cardiovascular diseases, at a population weighted mean cost of I$1.13 per capita over the 10 year intervention. The population weighted mean cost effectiveness ratio was approximately I$204/DALY. Across nine world regions, estimated cost effectiveness of sodium reduction was best in South Asia (I$116/DALY); across the world's 30 most populous countries, best in Uzbekistan (I$26.08/DALY) and Myanmar (I$33.30/DALY). Cost effectiveness was lowest in Australia/New Zealand (I$880/DALY, or 0.02×gross domestic product (GDP) per capita), although still substantially better than standard thresholds for cost effective (<3.0×GDP per capita) or highly cost effective (<1.0×GDP per capita) interventions. Most (96.0%) of the world's adult population lived in countries in which this intervention had a cost effectiveness ratio <0.1×GDP per capita, and 99.6% in countries with a cost effectiveness ratio <1.0×GDP per capita.

CONCLUSION

 A government "soft regulation" strategy combining targeted industry agreements and public education to reduce dietary sodium is projected to be highly cost effective worldwide, even without accounting for potential healthcare savings.