The Health Equity and Effectiveness of Policy Options to Reduce Dietary Salt Intake in England: Policy Forecast

The potential impact of policies and structural interventions in reducing cardiovascular disease and mortality: a systematic review of simulation-based studies

Background

The aim of the study was to investigate the potential effect of different structural interventions for preventing cardiovascular disease.

Methods

Medline and EMBASE were searched for peer-reviewed simulation-based studies of structural interventions for prevention of cardiovascular disease. We performed a systematic narrative synthesis.

Results

A total of 54 studies met the inclusion criteria. Diet, nutrition, tobacco and alcohol control and other programmes are among the policy simulation models explored. Food tax and subsidies, healthy food and lifestyles policies, palm oil tax, processed meat tax, reduction in ultra-processed foods, supplementary nutrition assistance programmes, stricter food policy and subsidised community-supported agriculture were among the diet and nutrition initiatives. Initiatives to reduce tobacco and alcohol use included a smoking ban, a national tobacco control initiative and a tax on alcohol. Others included the NHS Health Check, WHO 25 × 25 and air quality management policy.

Future work and limitations

There is significant heterogeneity in simulation models, making comparisons of output data impossible. While policy interventions typically include a variety of strategies, none of the models considered possible interrelationships between multiple policies or potential interactions. Research that investigates dose-response interactions between numerous modifications as well as longer-term clinical outcomes can help us better understand the potential impact of policy-level interventions.

Conclusions

The reviewed studies underscore the potential of structural interventions in addressing cardiovascular diseases. Notably, interventions in areas such as diet, tobacco, and alcohol control demonstrate a prospective decrease in cardiovascular incidents. However, to realize the full potential of such interventions, there is a pressing need for models that consider the interplay and cumulative impacts of multiple policies. Rigorous research into holistic and interconnected interventions will pave the way for more effective policy strategies in the future.

Study registration

The study is registered as PROSPERO CRD42019154836.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/148/05.

Exploring educational inequalities in hypertension control, salt knowledge and awareness, and patient advice: insights from the WHO STEPS surveys of adults from nine Eastern European and Central Asian countries

OBJECTIVE

To inform strategies aimed at improving blood pressure (BP) control and reducing salt intake, we assessed educational inequalities in high blood pressure (HBP) awareness, treatment and control; physician's advice on salt reduction; and salt knowledge, perceptions and consumption behaviours in Eastern Europe and Central Asia.

DESIGN

Data were collected in cross-sectional, population-based nationally representative surveys, using a multi-stage clustered sampling design. Five HBP awareness, treatment and control categories were created from measured BP and hypertension medication use. Education and other variables were self-reported. Weighted multinomial mixed-effects regression models, adjusted for confounders, were used to assess differences across education categories.

SETTINGS

Nine Eastern European and Central Asian countries (Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Turkey and Uzbekistan).

PARTICIPANTS

Nationally representative samples of 30 455 adults aged 25-65 years.

RESULTS

HBP awareness, treatment and control varied substantially by education. The coverage of physician's advice on salt was less frequent among participants with lower education, and those with untreated HBP or unaware of their HBP. The education gradient was evident in salt knowledge and perceptions of salt intake but not in salt consumption behaviours. Improved salt knowledge and perceptions were more prevalent among participants who received physician's advice on salt reduction.

CONCLUSIONS

There is a strong education gradient in HBP awareness, treatment and control as well as salt knowledge and perceived intake. Enhancements in public and patient knowledge and awareness of HBP and its risk factors targeting socio-economically disadvantaged groups are urgently needed to alleviate the growing HBP burden in low- and middle-income countries.

Modelling health and economic impact of nutrition interventions: a systematic review

Diet related non-communicable diseases (NCDs), as well as micronutrient deficiencies, are of widespread and growing importance to public health. Authorities are developing programs to improve nutrient intakes via foods. To estimate the potential health and economic impact of these programs there is a wide variety of models. The aim of this review is to evaluate existing models to estimate the health and/or economic impact of nutrition interventions with a focus on reducing salt and sugar intake and increasing vitamin D, iron, and folate/folic acid intake. The protocol of this systematic review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42016050873). The final search was conducted on PubMed and Scopus electronic databases and search strings were developed for salt/sodium, sugar, vitamin D, iron, and folic acid intake. Predefined criteria related to scientific quality, applicability, and funding/interest were used to evaluate the publications. In total 122 publications were included for a critical appraisal: 45 for salt/sodium, 61 for sugar, 4 for vitamin D, 9 for folic acid, and 3 for iron. The complexity of modelling the health and economic impact of nutrition interventions is dependent on the purpose and data availability. Although most of the models have the potential to provide projections of future impact, the methodological challenges are considerable. There is a substantial need for more guidance and standardization for future modelling, to compare results of different studies and draw conclusions about the health and economic impact of nutrition interventions.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam

OBJECTIVE

To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC).

DESIGN

Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy.

SETTING

Argentina, Mongolia, South Africa and Vietnam.

PARTICIPANTS

Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes.

RESULTS

Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts.

CONCLUSIONS

Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Disparities and spatial variations of high salt intake in Iran: a subnational study of districts based on the small area estimation method

OBJECTIVE

High salt intake is one of the leading diet-related risk factors for several non-communicable diseases. We aimed to estimate the prevalence of high salt intake in Iran.

DESIGN

A modelling study by the small area estimation method, based on a nationwide cross-sectional survey, Iran STEPwise approach to risk factor Surveillance (STEPS) 2016. The modelling estimated the prevalence of high salt intake, defined as a daily salt intake ≥ 5 g in all districts of Iran based on data from available districts. The modelling results were provided in different geographical and socio-economic scales to make the comparison possible across the country.

SETTING

429 districts of all provinces of Iran, 2016.

PARTICIPANTS

18 635 salt intake measurements from individuals 25 years old and above who participated in the Iran STEPS 2016 survey.

RESULTS

All districts in Iran had a high prevalence of high salt intake. The estimated prevalence of high salt intake among females of all districts ranged between 72·68 % (95 % UI 58·48, 84·81) and 95·04 % (95 % UI 87·10, 100). Estimated prevalence for males ranged between 88·44 % (95 % UI 80·29, 96·15) and 98·64 % (95 % UI 94·97, 100). In all categorisations, males had a significantly higher prevalence of high salt intake. Among females, the population with the lower economic status had a higher salt consumption than the participants with higher economic status by investigating the concentration index.

CONCLUSIONS

Findings of this study highlight the high salt intake as a prominent risk factor in all Iran regions, despite some variations in different scales. More suitable population-wide policies are warranted to handle this public health issue in Iran.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

Sodium intake, health implications, and the role of population-level strategies

Evidence to date suggests that high sodium intake affects health adversely, yet the role of a population-level strategy to reduce sodium intake is often contested. This review focuses on current available evidence on regional sodium intake levels, health implications of sodium intake, and population-level strategies implemented worldwide. The limitations in evidence, the difficulties in implementing population-wide strategies to reduce sodium intake, and the need for such strategies are critically reviewed. Evidence clearly shows that sodium has an adverse effect on blood pressure, cardiovascular disease, and mortality. However, whether reduced sodium intake benefits all individuals or only hypertensive individuals is still unclear. Methodological issues and publication bias in current evidence are other matters of concern in sodium-related research. While it is essential to continue working toward the World Health Organization's target of 30% reduction in sodium intake, due consideration should be given to improving the quality of research, reducing bias in publications, and reviewing evidence more critically.

The cost-effectiveness of government actions to reduce sodium intake through salt substitutes in Vietnam

Background

Dietary sodium reduction is recommended to reduce the burden of cardiovascular disease. In Vietnam food products including salt, fish sauce and bot canh contribute to ~ 70% of dietary sodium intake. Reduced sodium versions of these products can be produced by replacing some of the sodium chloride with potassium chloride. We aimed to assess the cost-effectiveness of three alternative approaches to introducing reduced sodium products onto the market with a view to lowering population sodium intake in Vietnam.

Methods

The three salt substitution strategies included voluntary, subsidised and regulatory approaches targeting salt, fish sauce and bot canh products. Costs were modelled using the WHO-CHOICE methodology. A Markov cohort model was developed to evaluate the cost-effectiveness of each strategy versus no intervention from the government perspective. The model linked each intervention strategy to assumed changes in levels of sodium intake and then to systolic blood pressure. Changes in SBP were linked to a probability of ischaemic heart disease or stroke. The model followed people over their lifetime to assess average costs and quality adjusted life years (QALYs) gained for each strategy.

Results

The voluntary salt substitution strategy was assumed to require no investment by government. Following ramp up (years 6+), the average annual costs for the subsidised and regulatory strategies were 21,808,968,902 ₫ (US$ 977,354) and 12,949,953,247 ₫ (US$ 580,410) respectively. Relative to no intervention, all three salt substitution strategies were found to be cost-effective. Cost savings were driven by reductions in strokes (32,595; 768,384; 2,366,480) and ischaemic heart disease (IHD) events (22,830; 537,157; 1,648,590) for the voluntary, subsidised & regulatory strategies, respectively. The voluntary strategy was least cost-effective (− 3445 ₫ US$ -0.15; 0.009 QALYs gained) followed by the subsidised strategy (− 43,189 ₫ US$ -1.86; 0.022 QALYs gained) and the regulatory strategy delivered the highest cost savings and health gains (− 243,530 ₫ US$ -10.49; 0.074 QALYs gained).

Conclusion

This research shows that all three modelled salt substitution strategies would be good value for money relative to no intervention in Vietnam. The subsidised alternative would require the highest level of government investment; however the implementation costs will be exceeded by healthcare savings assuming a reasonable time horizon is considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00540-4.

The Equity and Effectiveness of Achieving Canada's Voluntary Sodium Reduction Guidance Targets: A Modelling Study Using the 2015 Canadian Community Health Survey-Nutrition

Background: High sodium intake is a leading modifiable risk factor for cardiovascular diseases. This study estimated full compliance to Canada’s voluntary sodium reduction guidance (SRG) targets on social inequities and population sodium intake. Methods: We conducted a modeling study using n = 19,645, 24 h dietary recalls (Canadians ≥ 2 years) from the 2015 Canadian Community Health Survey—Nutrition (2015 CCHS-N). Multivariable linear regressions were used to estimate mean sodium intake in measured (in the 2015 CCHS-N) and modelled (achieving SRG targets) scenarios across education, income and food security. The percentage of Canadians with sodium intakes above chronic disease risk reduction (CDRR) thresholds was estimated using the US National Cancer Institute (NCI) method. Results: In children aged 2–8, achieving SRG targets reduced mean sodium intake differences between food secure and insecure households from 271 mg/day (95%CI: 75,468) to 83 mg/day (95%CI: −45,212); a finding consistent across education and income. Mean sodium intake inequities between low and high education households were eliminated for females aged 9–18 (96 mg/day, 95%CI: −149,341) and adults aged 19 and older (males: 148 mg/day, 95%CI: −30,327; female: −45 mg/day, 95%CI: −141,51). Despite these declines (after achieving the SRG targets) the majority of Canadians’ are above the CDRR thresholds. Conclusion: Achieving SRG targets would eliminate social inequities in sodium intake and reduce population sodium intake overall; however, additional interventions are required to reach recommended sodium levels.

Parents' Perceptions about Salt Consumption in Urban Areas of Peru: Formative Research for a Social Marketing Strategy

Background: Salt intakes in Latin America currently double the World Health Organization’s recommendation of 5 g/day. Various strategies to reduce the population’s salt consumption, such as raising awareness using social marketing, have been recommended. This study identified parents’ perceptions of salt consumption to inform a social marketing strategy focused on urban areas in Peru. Methods: Using a sequential exploratory methods design, parents of pre-school children, of high and low socioeconomic status, provided qualitative data in the form of interviews and focus groups. Following this, quantitative data was obtained via questionnaires, which were sent to all parents. The information was analyzed jointly. Results: 296 people (mean age 35.4, 82% women) participated, 64 in the qualitative and 232 in the quantitative phase of the study. Qualitative data from the first phase revealed that the majority of mothers were in charge of cooking, and female participants expressed that cooking was “their duty” as housewives. The qualitative phase also revealed that despite the majority of the participants considered their salt intake as adequate, half of them mentioned that they have tried to reduce salt consumption, and the change in the flavor of the food was stated as the most difficult challenge to continue with such practice. Quantitative data showed that 67% of participants would be willing to reduce their salt intake, and 79.7% recognized that high salt intake causes hypertension. In total, 84% of participants reaffirmed that mothers were in charge of cooking. There were no salient differences in terms of responses provided by participants from high versus low socioeconomic groups. Conclusions: The results point towards the identification of women as a potential target-audience of a social marketing strategy to promote reductions in salt intake in their families and, therefore, a gender-responsive social marketing intervention is recommended.

Disparities, variations, inequalities or inequities: whatever you call them, we need data to monitor them

Health inequalities are a problem in high, middle and low income countries. Most are unfair ('inequities') and could be minimised but primarily through policies outside the health service.In the US, the Center for Diseases Control has used high quality, nationally-available data to monitor conditions and determinants of health among different groups (by sex, disability, race, ethnicity, and language) to motivate action to reduce inequalities. In the UK, the 10 top level 'health' indicators in London at the turn of the millennium included unemployment, education, housing quality, crime, air pollution, road travel injuries, as well as traditional health measures. Most of these affect mental and physical health through social determinants or adverse environmental exposures. Current inequalities monitoring in England includes a Local Basket of Inequalities Indicators focusing on a wide range of determinants of health as well as traditional health metrics.Israel, like the US, has above average socio-economic inequalities but has universal healthcare. Health inequalities in Israel occur within different Jewish groups and by income, education, ethnicity, and religion, with disadvantages often clustering. Current monitoring in Israel focuses on health outcomes and 'midstream' healthcare-related provision. I agree with Abu-Saad and her colleagues that including monitoring of social determinants of health is crucial to identify and tackle health inequalities in Israel.National, 'upstream', interventions are the most effective ways to reduce inequalities and improve the population's health. High-level political support is crucial for this. While a 'Health in all Policies' approach combined with political will to 'leave no one behind' can lead to great improvements, regular monitoring is essential, to: identify the inequities; plan appropriate and effective, targeted interventions; implement and evaluate them; and change them where needed. All of this requires adequate and timely data on health and its determinants, including information about undiagnosed and poorly controlled disease, obtained from the general population not just those attending for healthcare, analysed for each population sub-group at risk of experiencing inequalities.This is a commentary on https://doi.org/10.1186/s13584-018-0208-1.

Interventions to accelerate change towards a healthier diet

Poor diets are a significant contributor to non-communicable diseases and obesity. Despite years of health promotion, change in dietary habits is slow and there is growing recognition of the need to provide greater support to individuals and to complement individual efforts with changes in the food environment to shift the default towards healthier diets. The present paper summarises opportunities for intervention at the individual and population level. It discusses the role of voluntary or mandatory approaches to drive change in the food industry and the need for improved methods to monitor and evaluate progress. It concludes with a call to action from all stakeholders to accelerate change towards a healthier diet.

The impact of food reformulation on nutrient intakes and health, a systematic review of modelling studies

BACKGROUND

Unhealthy diet is a risk factor for adverse health outcomes. Reformulation of processed foods has the potential to improve population diet, but evidence of its impact is limited. The purpose of this review was to explore the impact of reformulation on nutrient intakes, health outcomes and quality of life; and to evaluate the quality of modelling studies on reformulation interventions.

METHODS

A systematic review of peer-reviewed articles published between January 2000 and December 2017 was performed using MEDLINE, ScienceDirect, Embase, Scopus, Cochrane, and the Centre for Reviews and Dissemination of the University of York. Additional studies were identified through informal searches on Google and specialized websites. Only simulation studies modelling the impact of food reformulation on nutrient intakes and health outcomes were included. Included articles were independently extracted by 2 reviewers using a standardized, pre-piloted data form, including a self-developed tool to assess study quality.

RESULTS

A total of 33 studies met the selected inclusion criteria, with 20, 5 and 3 studies addressing sodium, sugar and fats reformulation respectively, and 5 studies addressing multiple nutrients. Evidence on the positive effects of reformulation on consumption and health was stronger for sodium interventions, less conclusive for sugar and fats. Study features were highly heterogeneous including differences in methods, the type of policy implemented, the extent of the reformulation, and the spectrum of targeted foods and nutrients. Nonetheless, partial between-study comparisons show a consistent relationship between percentages reformulated and reductions in individual consumption. Positive results are also shown for health outcomes and quality of life measures, although comparisons across studies are limited by the heterogeneity in model features and reporting. Study quality was often compromised by short time-horizons, disregard of uncertainty and time dependencies, and lack of model validation.

CONCLUSIONS

Reformulation models highlight relevant improvements in diets and population health. While models are valuable tools to evaluate reformulation interventions, comparisons are limited by non-homogeneous designs and assumptions. The use of validated models and extensive scenario analyses would improve models' credibility, providing useful insights for policy-makers.

REVIEW REGISTRATION

A research protocol was registered within the PROSPERO database (ID number CRD42017057341).

The Twin White Herrings: Salt and Sugar

India has the dubious distinction of being a hotspot for both diabetes and hypertension. Increased salt and sugar consumption is believed to fuel these two epidemics. This review is an in-depth analysis of current medical literature on salt and sugar being the two white troublemakers of modern society. The PubMed, Medline, and Embase search for articles published in January 2018, using the terms "salt" [MeSH Terms] OR "sodium chloride" [All Fields] OR "sugar" [All Fields]. India is world's highest consumer of sugar with one of the highest salt consumption per day. Increased salt intake is associated with increased risk of hypertension, left ventricular hypertrophy and fibrosis, cardiovascular events, renal stones, proteinuria, and renal failure. Increased sugar intake is directly linked to increased risk of obesity, fatty liver disease, and metabolic syndrome. Also, increased sugar intake may be indirectly related to the increased risk of type 2 diabetes. Both salt and sugar intake is directly linked to increased systemic and hypothalamic inflammation, endothelial dysfunction, microangiopathy, cardiovascular remodelling, cancers, and death. High fructose corn is especially damaging. There is no safe limit of sugar consumption, as the human body can produce its own glucose. Being nature's gift to mankind, there is no harm in moderate consumption of salt and sugar, however, modest reduction in the consumption of both can substantially reduce the burden of non-communicable diseases. Public health interventions to facilitate this behavioural change must be instituted and encouraged.

Cardiovascular disease and high blood pressure trend analyses from 2002 to 2016: after the implementation of a salt reduction strategy

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death around the world; however, many CVD events could be prevented if we focused on modification of the main risk factors. Increased salt consumption is estimated to have caused millions of deaths, mostly related to CVD, particularly stroke, which is the leading cause of death in Portugal. In our study, we aim to assess trends in the proportion of high blood pressure (HBP) in Acute Coronary Syndrome (ACS) patients as well as the trends in stroke and ACS in Portugal, especially after a set of public health initiatives were implemented to reduce salt intake.

METHODS

The monthly proportion of ACS patients presenting with previously diagnosed HBP and the monthly rate of CVD admissions into public hospitals in Portugal were calculated. CVD rates were stratified into ACS rate and stroke rates. Data were stratified by demographics variables. An interrupted time-series model was used to assess changes over time.

RESULTS

Breakpoint analysis revealed an estimated breakpoint around the year 2013 for the proportion of HBP patients, the following year there was a decreasing trend, however it was not significant. Analyses showed the trend before 2013 was increasing and started to decrease after this year. This decreased in proportion of HBP patients can be translated into a reduction of 555 people per year presenting with HBP in the ACS population. We analysed trends for ACS and stroke and tested the significance for a breakpoint in the year 2013. Although none of the remaining trends were significant for ACS crude rates and stroke crude rate, a decreasing trend was observed.

CONCLUSIONS

This research provides an indication about the impact a population-wide approach to CVD risk factors has on CVD trends themselves. Our results suggest that population-wide approaches can have an impact on the prevention and improvement of CVD control, reducing the number of CVD events, and eventually reducing premature death by CVD. As more restrictions on salt intake are being planned in Portugal in the next years, it is highly relevant to assess what is the current panorama and what further reductions we can expect.

Modelling impacts of food industry co-regulation on noncommunicable disease mortality, Portugal

Objective

To model the reduction in premature deaths attributed to noncommunicable diseases if targets for reformulation of processed food agreed between the Portuguese health ministry and the food industry were met.

Methods

The 2015 co-regulation agreement sets voluntary targets for reducing sugar, salt and trans-fatty acids in a range of products by 2021. We obtained government data on dietary intake in 2015–2016 and on population structure and deaths from four major noncommunicable diseases over 1990–2016. We used the Preventable Risk Integrated ModEl tool to estimate the deaths averted if reformulation targets were met in full. We projected future trends in noncommunicable disease deaths using regression modelling and assessed whether Portugal was on track to reduce baseline premature deaths from noncommunicable diseases in the year 2010 by 25% by 2025, and by 30% before 2030.

Findings

If reformulation targets were met, we projected reductions in intake in 2015–2016 for salt from 7.6 g/day to 7.1 g/day; in total energy from 1911 kcal/day to 1897 kcal/day due to reduced sugar intake; and in total fat (% total energy) from 30.4% to 30.3% due to reduced trans-fat intake. This consumption profile would result in 248 fewer premature noncommunicable disease deaths (95% CI: 178 to 318) in 2016. We projected that full implementation of the industry agreement would reduce the risk of premature death from 11.0% in 2016 to 10.7% by 2021.

Conclusion

The co-regulation agreement could save lives and reduce the risk of premature death in Portugal. Nevertheless, the projected impact on mortality was insufficient to meet international targets.

Food reformulation and nutritional quality of food consumption: an analysis based on households panel data in France

Background/objectives

We aimed to quantify the contribution of food reformulation to changes in the nutritional quality of consumers’ food purchases, and compare it with the impact of substitutions made by consumers.

Subjects/methods

Using a brand-specific data set in France, we considered the changes in the nutrient content of food products in four food sectors over a 3-year period. These data were matched with data on consumers’ purchases to estimate the change in the nutritional quality of consumers’ purchases. This change was divided into three components: the reformulation of food products, the launching of new products and the consumers’ substitutions between products. Key nutrients were selected for each food group: breakfast cereals (sugar, fats, SFA, fiber, and sodium), biscuits and cakes (sugar, fats, SFA, and fiber), potato chips (fats, SFA, and sodium) and soft drinks (sugar).

Results

Product reformulation initiatives have improved existing products for most food group-nutrient pairs. In particular, the contribution of food reformulation to the change in nutritional quality of food purchases was strong in potato chips (the sales-weighted mean SFA and sodium contents decreased by 31.4% to 52.1% and 6.7% to 11.1%, respectively), and breakfast cereals (the sales-weighted mean sodium content decreased by 7.3% to 9.7%). Regarding the launching of new products, the results were ambiguous. Consumers’ substitutions between food items were not generally associated to an improvement in the nutritional quality of the food purchases.

Conclusions

Policies aiming to promote food reformulation may have greater impact than those promoting changes in consumer behavior.

Systematic review of dietary salt reduction policies: Evidence for an effectiveness hierarchy?

BACKGROUND

Non-communicable disease (NCD) prevention strategies now prioritise four major risk factors: food, tobacco, alcohol and physical activity. Dietary salt intake remains much higher than recommended, increasing blood pressure, cardiovascular disease and stomach cancer. Substantial reductions in salt intake are therefore urgently needed. However, the debate continues about the most effective approaches. To inform future prevention programmes, we systematically reviewed the evidence on the effectiveness of possible salt reduction interventions. We further compared "downstream, agentic" approaches targeting individuals with "upstream, structural" policy-based population strategies.

METHODS

We searched six electronic databases (CDSR, CRD, MEDLINE, SCI, SCOPUS and the Campbell Library) using a pre-piloted search strategy focussing on the effectiveness of population interventions to reduce salt intake. Retrieved papers were independently screened, appraised and graded for quality by two researchers. To facilitate comparisons between the interventions, the extracted data were categorised using nine stages along the agentic/structural continuum, from "downstream": dietary counselling (for individuals, worksites or communities), through media campaigns, nutrition labelling, voluntary and mandatory reformulation, to the most "upstream" regulatory and fiscal interventions, and comprehensive strategies involving multiple components.

RESULTS

After screening 2,526 candidate papers, 70 were included in this systematic review (49 empirical studies and 21 modelling studies). Some papers described several interventions. Quality was variable. Multi-component strategies involving both upstream and downstream interventions, generally achieved the biggest reductions in salt consumption across an entire population, most notably 4g/day in Finland and Japan, 3g/day in Turkey and 1.3g/day recently in the UK. Mandatory reformulation alone could achieve a reduction of approximately 1.45g/day (three separate studies), followed by voluntary reformulation (-0.8g/day), school interventions (-0.7g/day), short term dietary advice (-0.6g/day) and nutrition labelling (-0.4g/day), but each with a wide range. Tax and community based counselling could, each typically reduce salt intake by 0.3g/day, whilst even smaller population benefits were derived from health education media campaigns (-0.1g/day). Worksite interventions achieved an increase in intake (+0.5g/day), however, with a very wide range. Long term dietary advice could achieve a -2g/day reduction under optimal research trial conditions; however, smaller reductions might be anticipated in unselected individuals.

CONCLUSIONS

Comprehensive strategies involving multiple components (reformulation, food labelling and media campaigns) and "upstream" population-wide policies such as mandatory reformulation generally appear to achieve larger reductions in population-wide salt consumption than "downstream", individually focussed interventions. This 'effectiveness hierarchy' might deserve greater emphasis in future NCD prevention strategies.

Effect of 25% Sodium Reduction on Sales of a Top-Selling Bread in Remote Indigenous Australian Community Stores: A Controlled Intervention Trial

Reducing sodium in the food supply is key to achieving population salt targets, but maintaining sales is important to ensuring commercial viability and maximising clinical impact. We investigated whether 25% sodium reduction in a top-selling bread affected sales in 26 remote Indigenous community stores. After a 23-week baseline period, 11 control stores received the regular-salt bread (400 mg Na/100 g) and 15 intervention stores received the reduced-salt version (300 mg Na/100 g) for 12-weeks. Sales data were collected to examine difference between groups in change from baseline to follow-up (effect size) in sales (primary outcome) or sodium density, analysed using a mixed model. There was no significant effect on market share (-0.31%; 95% CI -0.68, 0.07; p = 0.11) or weekly dollars ($58; -149, 266; p = 0.58). Sodium density of all purchases was not significantly reduced (-8 mg Na/MJ; -18, 2; p = 0.14), but 25% reduction across all bread could significantly reduce sodium (-12; -23, -1; p = 0.03). We found 25% salt reduction in a top-selling bread did not affect sales in remote Indigenous community stores. If achieved across all breads, estimated salt intake in remote Indigenous Australian communities would be reduced by approximately 15% of the magnitude needed to achieve population salt targets, which could lead to significant health gains at the population-level.

Estimated reductions in cardiovascular and gastric cancer disease burden through salt policies in England: an IMPACTNCD microsimulation study

OBJECTIVE

To estimate the impact and equity of existing and potential UK salt reduction policies on primary prevention of cardiovascular disease (CVD) and gastric cancer (GCa) in England.

DESIGN

A microsimulation study of a close-to-reality synthetic population. In the first period, 2003-2015, we compared the impact of current policy against a counterfactual 'no intervention' scenario, which assumed salt consumption persisted at 2003 levels. For 2016-2030, we assumed additional legislative policies could achieve a steeper salt decline and we compared this against the counterfactual scenario that the downward trend in salt consumption observed between 2001 and 2011 would continue up to 2030.

SETTING

Synthetic population with similar characteristics to the non-institutionalised population of England.

PARTICIPANTS

Synthetic individuals with traits informed by the Health Survey for England.

MAIN MEASURE

CVD and GCa cases and deaths prevented or postponed, stratified by fifths of socioeconomic status using the Index of Multiple Deprivation.

RESULTS

Since 2003, current salt policies have prevented or postponed ∼52 000 CVD cases (IQR: 34 000-76 000) and 10 000 CVD deaths (IQR: 3000-17 000). In addition, the current policies have prevented ∼5000 new cases of GCa (IQR: 2000-7000) resulting in about 2000 fewer deaths (IQR: 0-4000). This policy did not reduce socioeconomic inequalities in CVD, and likely increased inequalities in GCa. Additional legislative policies from 2016 could further prevent or postpone ∼19 000 CVD cases (IQR: 8000-30 000) and 3600 deaths by 2030 (IQR: -400-8100) and may reduce inequalities. Similarly for GCa, 1200 cases (IQR: -200-3000) and 700 deaths (IQR: -900-2300) could be prevented or postponed with a neutral impact on inequalities.

CONCLUSIONS

Current salt reduction policies are powerfully effective in reducing the CVD and GCa burdens overall but fail to reduce the inequalities involved. Additional structural policies could achieve further, more equitable health benefits.

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.

Interventions promoting healthy eating as a tool for reducing social inequalities in diet in low- and middle-income countries: a systematic review

Introduction

Diet is a major risk factor for non-communicable diseases (NCDs) and is also strongly patterned by socioeconomic factors. Whether interventions promoting healthy eating reduce social inequalities in diet in low- and middle-income countries (LMICs) remains uncertain. This paper aims to summarize current evidence on interventions promoting healthy eating in LMICs, and to establish whether they reduce social inequalities in diet.

Methods

Systematic review of cross-sectional or quasi-experimental studies (pre- and post-assessment of interventions) in Pubmed, Scielo and Google Scholar databases, including adults in LMICs, assessing at least one outcome of healthy eating and showing results stratified by socioeconomic status.

Results

Seven intervention studies including healthy eating promotion, conducted in seven LMICs (Brazil, Chile, Colombia, Iran, Panama, Trinidad and Tobago, and Tunisia), met our inclusion criteria. To promote healthy eating, all interventions used nutrition education and three of them combined nutrition education with improved acces to foods or social support. Interventions targeted mostly women and varied widely regarding communication tools and duration of the nutrition education sessions. Most interventions used printed material, media use or face-to-face training and lasted from 6 weeks to 5 years. Four interventions targeted disadvantaged populations, and three targeted the entire population. In three out of four interventions targeting disadvantaged populations, healthy eating outcomes were improved suggesting they were likely to reduce social inequalities in diet. All interventions directed to the entire population showed improved healthy eating outcomes in all social strata, and were considered as having no impact on social inequalities in diet.

Conclusion

In LMICs, agentic interventions promoting healthy eating reduced social inequalities in diet when specifically targeting disadvantaged populations. Further research should assess the impact on social inequalities in diet of a combination of agentic and structural approaches in interventions promoting healthy eating.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0489-3) contains supplementary material, which is available to authorized users.

Cardiovascular screening to reduce the burden from cardiovascular disease: microsimulation study to quantify policy options

OBJECTIVES

 To estimate the potential impact of universal screening for primary prevention of cardiovascular disease (National Health Service Health Checks) on disease burden and socioeconomic inequalities in health in England, and to compare universal screening with alternative feasible strategies.

DESIGN

 Microsimulation study of a close-to-reality synthetic population. Five scenarios were considered: baseline scenario, assuming that current trends in risk factors will continue in the future; universal screening; screening concentrated only in the most deprived areas; structural population-wide intervention; and combination of population-wide intervention and concentrated screening.

SETTING

 Synthetic population with similar characteristics to the community dwelling population of England.

PARTICIPANTS

 Synthetic people with traits informed by the health survey for England.

MAIN OUTCOME MEASURE

 Cardiovascular disease cases and deaths prevented or postponed by 2030, stratified by fifths of socioeconomic status using the index of multiple deprivation.

RESULTS

 Compared with the baseline scenario, universal screening may prevent or postpone approximately 19 000 cases (interquartile range 11 000-28 000) and 3000 deaths (-1000-6000); concentrated screening 17 000 cases (9000-26 000) and 2000 deaths (-1000-5000); population-wide intervention 67 000 cases (57 000-77 000) and 8000 deaths (4000-11 000); and the combination of the population-wide intervention and concentrated screening 82 000 cases (73 000-93 000) and 9000 deaths (6000-13 000). The most equitable strategy would be the combination of the population-wide intervention and concentrated screening, followed by concentrated screening alone and the population-wide intervention. Universal screening had the least apparent impact on socioeconomic inequalities in health.

CONCLUSIONS

 When primary prevention strategies for reducing cardiovascular disease burden and inequalities are compared, universal screening seems less effective than alternative strategies, which incorporate population-wide approaches. Further research is needed to identify the best mix of population-wide and risk targeted CVD strategies to maximise cost effectiveness and minimise inequalities.

Modeling health gains and cost savings for ten dietary salt reduction targets

BACKGROUND

Dietary salt reduction is included in the top five priority actions for non-communicable disease control internationally. We therefore aimed to identify health gain and cost impacts of achieving a national target for sodium reduction, along with component targets in different food groups.

METHODS

We used an established dietary sodium intervention model to study 10 interventions to achieve sodium reduction targets. The 2011 New Zealand (NZ) adult population (2.3 million aged 35+ years) was simulated over the remainder of their lifetime in a Markov model with a 3 % discount rate.

RESULTS

Achieving an overall 35 % reduction in dietary salt intake via implementation of mandatory maximum levels of sodium in packaged foods along with reduced sodium from fast foods/restaurant food and discretionary intake (the "full target"), was estimated to gain 235,000 QALYs over the lifetime of the cohort (95 % uncertainty interval [UI]: 176,000 to 298,000). For specific target components the range was from 122,000 QALYs gained (for the packaged foods target) down to the snack foods target (6100 QALYs; and representing a 34-48 % sodium reduction in such products). All ten target interventions studied were cost-saving, with the greatest costs saved for the mandatory "full target" at NZ$1260 million (US$820 million). There were relatively greater health gains per adult for men and for Māori (indigenous population).

CONCLUSIONS

This work provides modeling-level evidence that achieving dietary sodium reduction targets (including specific food category targets) could generate large health gains and cost savings for a national health sector. Demographic groups with the highest cardiovascular disease rates stand to gain most, assisting in reducing health inequalities between sex and ethnic groups.

Keeping Public Health Clean: Food Policy Barriers and Opportunities in the Era of the Industrial Epidemics

Poor diet accounts for a larger burden of disability and death than tobacco, alcohol and physical inactivity combined.[1] The World Health Assembly has recognized this as a priority and has challenged member countries to reduce non-communicable disease (NCD) mortality by 25% by 2025 targeting their determinants.[2] Reaching these ambitious targets is possible, but it will require decisive action on diets and tobacco smoking if we want to make a difference.[1] Certainly diet can deliver these reductions rapidly, possibly in less than a decade, and particularly by reducing cardiovascular disease burden, still one of the most important cause of death globally. [3],[4]

But the impact of these diseases can be substantially lowered. Several natural experiments have shown the dramatic changes in mortality can be observed after changes of risk factors at population level, many attributable to changes in food intake [5]

Projected Impact of Salt Restriction on Prevention of Cardiovascular Disease in China: A Modeling Study

Objectives

To estimate the effects of achieving China’s national goals for dietary salt (NaCl) reduction or implementing culturally-tailored dietary salt restriction strategies on cardiovascular disease (CVD) prevention.

Methods

The CVD Policy Model was used to project blood pressure lowering and subsequent downstream prevented CVD that could be achieved by population-wide salt restriction in China. Outcomes were annual CVD events prevented, relative reductions in rates of CVD incidence and mortality, quality-adjusted life-years (QALYs) gained, and CVD treatment costs saved.

Results

Reducing mean dietary salt intake to 9.0 g/day gradually over 10 years could prevent approximately 197 000 incident annual CVD events [95% uncertainty interval (UI): 173 000–219 000], reduce annual CVD mortality by approximately 2.5% (2.2–2.8%), gain 303 000 annual QALYs (278 000–329 000), and save approximately 1.4 billion international dollars (Int$) in annual CVD costs (Int$; 1.2–1.6 billion). Reducing mean salt intake to 6.0 g/day could approximately double these benefits. Implementing cooking salt-restriction spoons could prevent 183 000 fewer incident CVD cases (153 000–215 000) and avoid Int$1.4 billion in CVD treatment costs annually (1.2–1.7 billion). Implementing a cooking salt substitute strategy could lead to approximately three times the health benefits of the salt-restriction spoon program. More than three-quarters of benefits from any dietary salt reduction strategy would be realized in hypertensive adults.

Conclusion

China could derive substantial health gains from implementation of population-wide dietary salt reduction policies. Most health benefits from any dietary salt reduction program would be realized in adults with hypertension.