Potassium-Enriched Salt Substitutes: A Review of Recommendations in Clinical Management Guidelines

Excess dietary sodium intake and insufficient dietary potassium intake are both well-established risk factors for hypertension. Despite some successful initiatives, efforts to control hypertension by improving dietary intake have largely failed because the changes required are mostly too hard to implement. Consistent recent data from randomized controlled trials show that potassium-enriched, sodium-reduced salt substitutes are an effective option for improving consumption levels and reducing blood pressure and the rates of cardiovascular events and deaths. Yet, salt substitutes are inconsistently recommended and rarely used. We sought to define the extent to which evidence about the likely benefits and harms of potassium-enriched salt substitutes has been incorporated into clinical management by systematically searching guidelines for the management of hypertension or chronic kidney disease. We found incomplete and inconsistent recommendations about the use of potassium-enriched salt substitutes in the 32 hypertension and 14 kidney guidelines that we reviewed. Discussion among the authors identified the possibility of updating clinical guidelines to provide consistent advice about the use of potassium-enriched salt for hypertension control. Draft wording was chosen to commence debate and progress consensus building: strong recommendation for patients with hypertension-potassium-enriched salt with a composition of 75% sodium chloride and 25% potassium chloride should be recommended to all patients with hypertension, unless they have advanced kidney disease, are using a potassium supplement, are using a potassium-sparing diuretic, or have another contraindication. We strongly encourage clinical guideline bodies to review their recommendations about the use of potassium-enriched salt substitutes at the earliest opportunity.

The availability, price, and characteristics of low sodium salt based on an online salt market survey in China: Implications for scaling up its use

Low sodium salt (LSS) is an effective way to reduce the primary source of sodium from home cooking. To investigate the availability, price and characteristics of LSS, price gap between LSS and regular salt, and the potential size of subsidy needed to equalize the price of LSS and regular salt. A market survey of salts was conducted using two major online shopping sites JD and Taobao from November to December 2022. Of 360 salts, 76 (21.1%) are LSS and 284 (78.9%) are regular salt. The average proportion of potassium chloride is low (16.8%), and half of the brands contain less than 15% and only 6.6% contains ≥25%. The mean price of LSS is slightly but not significantly higher than that of regular salts (1.82 versus 1.67 yuan/100 g, p = .07). In the lowest quartile by price, the cost of LSS is significantly higher than regular salts (difference 0.13, p = .0048). Further, when comparing the lowest price LSS to the lowest price regular since within the same brand, the mean price LSS is 2.11-fold that of the regular salt (1.66 versus 0.79 yuan/100 g, p < .05). The price of iodized LSS is also significantly higher than that of iodized regular salt (1.86 verse 1.44 yuan/100 g, p = .044). An annual subsidy based on the difference in price in the first quartile would cost 4.75 yuan per capita. A variety of LSS are available in China's salt market.

Considerations for modelling a broad food tax in the Philippines and other low-income and middle-income countries

Fiscal policies to improve diet are a promising strategy to address the increasing burden of non-communicable disease, the leading cause of death globally. Sugar-sweetened beverage taxes are the most implemented type of fiscal policy to improve diet. Yet taxes on food, if appropriately structured and applied across the food supply, may support a larger population-level shift towards a healthier diet. Designing these policies and guiding them through the legislative process requires evidence. Equity-oriented cost-effectiveness analyses that estimate the distribution of potential health and economic gains can provide this critical evidence. Taxes on less healthy foods are rarely modelled in low-income and middle-income countries.We describe considerations for modelling the effect of a food tax, which can provide guidance for food tax policy design. This includes describing issues related to the availability, reliability and level of detail of national data on dietary habits, the nutrient content of foods and food prices; the structure of the nutrient profile model; type of tax; tax rate; pass-through rate and price elasticity. Using the Philippines as an example, we discuss considerations for using existing data to model the potential effect of a tax, while also taking into account the political and food policy context. In this way, we provide a modelling framework that can help guide policy-makers and advocates in designing a food policy to improve the health and well-being of future generations in the Philippines and elsewhere.

Estimated health benefits, costs and cost-effectiveness of eliminating dietary industrial trans fatty acids in Kenya: cost-effectiveness analysis

OBJECTIVES

To model the potential health gains and cost-effectiveness of a mandatory limit of industrial trans fatty acids (iTFA) in Kenyan foods.

DESIGN

Multiple cohort proportional multistate life table model, incorporating existing data from the Global Burden of Disease study, pooled analyses of observational studies and peer-reviewed evidence of healthcare and policy implementation costs.

SETTING

Kenya.

PARTICIPANTS

Adults aged ≥20 years at baseline (n=50 million).

INTERVENTION

A mandatory iTFA limit (≤2% of all fats) in the Kenyan food supply compared with a base case scenario of maintaining current trans fat intake.

MAIN OUTCOME MEASURES

Averted ischaemic heart disease (IHD) events and deaths, health-adjusted life years; healthcare costs; policy implementation costs; net costs; and incremental cost-effectiveness ratio.

RESULTS

Over the first 10 years, the intervention was estimated to prevent ~1900 (95% uncertainty interval (UI): 1714; 2148) IHD deaths and ~17 000 (95% UI: 15 475; 19 551) IHD events, and to save ~US$50 million (95% UI: 44; 56). The corresponding estimates over the lifespan of the model population were ~49 000 (95% UI: 43 775; 55 326) IHD deaths prevented, ~113 000 (95% UI: 100 104; 127 969) IHD events prevented and some ~US$300 million (256; 331) saved. Policy implementation costs were estimated as ~US$9 million over the first 10 years and ~US$20 million over the population lifetime. The intervention was estimated to be cost saving regardless of the time horizon. Findings were robust across multiple sensitivity analyses.

CONCLUSIONS

Findings support policy action for a mandatory iTFA limit as a cost-saving strategy to avert IHD events and deaths in Kenya.

'Love with Less Salt': evaluation of a sodium reduction mass media campaign in China

OBJECTIVE

This study examines the impact of a salt reduction campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change relating to salt consumption in two provinces of China.

METHODS

In 2019, the 'Love with Less Salt' campaign ran on China Central Television and on local television channels in Shandong and Anhui provinces. Data for this study come from two representative household surveys conducted among a sample of adults aged 25-65 years in Shandong and Anhui provinces: precampaign (n=2000) and postcampaign (n=2015). Logistic regression was performed to estimate the effects of the campaign on knowledge, attitudes, intentions, behaviours and barriers to behaviour change.

RESULTS

Overall, 13% of postcampaign respondents recalled seeing the campaign, and reactions towards the campaign were positive. Postcampaign respondents were more likely to plan to reduce their purchase of foods high in salt than precampaign respondents (OR=1.45, p=<0.05). Campaign-aware respondents were significantly more likely than campaign-unaware respondents to report higher levels of knowledge, attitudes and behaviours regarding salt reduction.

CONCLUSIONS

Findings reveal that salt reduction mass media campaigns can be an effective public health tool to support efforts to reduce salt consumption in China. Continued and sustained mass media investments are likely to be effective in addressing high salt consumption nationwide.

Delayed Finalization of Sodium Targets in the United States May Cost Over 250 000 Lives by 2031

BACKGROUND

The US Food and Drug Administration (FDA) proposed 2- and 10-year voluntary sodium-reduction targets for >150 packaged- and prepared-food categories in 2016 and finalized the short-term targets in 2021.

METHODS

We modeled the health benefits of implementing the newly finalized sodium targets, and the net health losses because of the 4.3-year delay in finalizing the sodium targets in different compliance scenarios in adults aged ≥30, using the National Health and Nutrition Examination Survey (NHANES) 2015 to 2016 cycle. The health impact was estimated by multiplying the projected reduction in population sodium intake by the annual health benefits resulting from every 1000-mg reduction in daily sodium intake.

RESULTS

Under certain assumptions, the FDA's finalization of the short-term targets in Oct 2021 and possible finalization of the long-term targets by April 2024 is projected to save up to 445 979 (95% CI, 17 349-787 352) lives in the coming 10 years. The net number of unnecessary deaths because of FDA's delay is projected to be as high as 264 644 (95% CI, 10 295-467 215) according to our prediction.

CONCLUSIONS

These findings highlight the enormous health costs due to the FDA's delay in finalizing the sodium-reduction targets, and the great potential health benefits of industry compliance with the FDA's finalization of its short- and long-term targets in the coming 10 years.

Cost assessment of a program for laboratory testing of plasma trans-fatty acids in Thailand

Objectives

Intake of trans fatty acids (TFA) increases the risk of cardiovascular disease. Assessment of TFA exposure in the population is key for determining TFA burden and monitoring change over time. One approach for TFA monitoring is measurement of TFA levels in plasma. Understanding costs associated with this approach can facilitate program planning, implementation and scale-up. This report provides an assessment of costs associated with a pilot program to measure plasma TFA levels in Thailand.

Study design

Cost analysis in a laboratory facility in Thailand.

Methods

We defined three broad cost modules: laboratory, personnel, and facility costs, which were further classified into sub-components and into fixed and variable categories. Costs were estimated based on the number of processed plasma samples (100–2700 in increments of 50) per year over a certain number of years (1–5), in both USD and Thai Baht. Total cost and average costs per sample were estimated across a range of samples processed.

Results

The average cost per sample of analyzing 900 samples annually over 5 years was estimated at USD186. Laboratory, personnel, and facility costs constitute 67%, 23%, and 10% of costs, respectively. The breakdown across fixed costs, such as laboratory instruments and personnel, and variable costs, such as chemical supplies, was 60% and 40%, respectively. Average costs decline as more samples are processed: the cost per sample for analyzing 100, 500, 1500, and 2500 samples per year over 5 years is USD1351, USD301, USD195; and USD177, respectively.

Conclusions

Laboratory analysis of plasma TFA levels has high potential for economies of scale, encouraging a long-term approach to TFA monitoring initiatives, particularly in countries that already maintain national biometric repositories.

Impact of color-coded and warning nutrition labelling schemes: A systematic review and network meta-analysis

BACKGROUND

Suboptimal diets are a leading risk factor for death and disability. Nutrition labelling is a potential method to encourage consumers to improve dietary behaviour. This systematic review and network meta-analysis (NMA) summarises evidence on the impact of colour-coded interpretive labels and warning labels on changing consumers' purchasing behaviour.

METHODS AND FINDINGS

We conducted a literature review of peer-reviewed articles published between 1 January 1990 and 24 May 2021 in PubMed, Embase via Ovid, Cochrane Central Register of Controlled Trials, and SCOPUS. Randomised controlled trials (RCTs) and quasi-experimental studies were included for the primary outcomes (measures of changes in consumers' purchasing and consuming behaviour). A frequentist NMA method was applied to pool the results. A total of 156 studies (including 101 RCTs and 55 non-RCTs) nested in 138 articles were incorporated into the systematic review, of which 134 studies in 120 articles were eligible for meta-analysis. We found that the traffic light labelling system (TLS), nutrient warning (NW), and health warning (HW) were associated with an increased probability of selecting more healthful products (odds ratios [ORs] and 95% confidence intervals [CIs]: TLS, 1.5 [1.2, 1.87]; NW, 3.61 [2.82, 4.63]; HW, 1.65 [1.32, 2.06]). Nutri-Score (NS) and warning labels appeared effective in reducing consumers' probability of selecting less healthful products (NS, 0.66 [0.53, 0.82]; NW,0.65 [0.54, 0.77]; HW,0.64 [0.53, 0.76]). NS and NW were associated with an increased overall healthfulness (healthfulness ratings of products purchased using models such as FSAm-NPS/HCSP) by 7.9% and 26%, respectively. TLS, NS, and NW were associated with a reduced energy (total energy: TLS, -6.5%; NS, -6%; NW, -12.9%; energy per 100 g/ml: TLS, -3%; NS, -3.5%; NW, -3.8%), sodium (total sodium/salt: TLS, -6.4%; sodium/salt per 100 g/ml: NS: -7.8%), fat (total fat: NS, -15.7%; fat per 100 g/ml: TLS: -2.6%; NS: -3.2%), and total saturated fat (TLS, -12.9%; NS: -17.1%; NW: -16.3%) content of purchases. The impact of TLS, NS, and NW on purchasing behaviour could be explained by improved understanding of the nutrition information, which further elicits negative perception towards unhealthful products or positive attitudes towards healthful foods. Comparisons across label types suggested that colour-coded labels performed better in nudging consumers towards the purchase of more healthful products (NS versus NW: 1.51 [1.08, 2.11]), while warning labels have the advantage in discouraging unhealthful purchasing behaviour (NW versus TLS: 0.81 [0.67, 0.98]; HW versus TLS: 0.8 [0.63, 1]). Study limitations included high heterogeneity and inconsistency in the comparisons across different label types, limited number of real-world studies (95% were laboratory studies), and lack of long-term impact assessments.

CONCLUSIONS

Our systematic review provided comprehensive evidence for the impact of colour-coded labels and warnings in nudging consumers' purchasing behaviour towards more healthful products and the underlying psychological mechanism of behavioural change. Each type of label had different attributes, which should be taken into consideration when making front-of-package nutrition labelling (FOPL) policies according to local contexts. Our study supported mandatory front-of-pack labelling policies in directing consumers' choice and encouraging the food industry to reformulate their products.

PROTOCOL REGISTRY

PROSPERO (CRD42020161877).

Barriers and Facilitators to Implementing Reduced-Sodium Salts as a Population-Level Intervention: A Qualitative Study

Widespread use of reduced-sodium salts can potentially lower excessive population-level dietary sodium intake. This study aimed to identify key barriers and facilitators to implementing reduced-sodium salt as a population level intervention. Semi-structured interviews were conducted with key informants from academia, the salt manufacturing industry, and government. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to inform our interview guides and data analysis. Eighteen key informants from nine countries across five World Health Organization regions participated in the study from January 2020 to July 2020. Participants were concerned about the lack of robust evidence on safety for specific populations such as those with renal impairment. Taste and price compared to regular salt and an understanding of the potential health benefits of reduced-sodium salt were identified as critical factors influencing the adoption of reduced-sodium salts. Higher production costs, low profit return, and reduced market demand for reduced-sodium salts were key barriers for industry in implementation. Participants provided recommendations as potential strategies to enhance the uptake. There are presently substantial barriers to the widespread use of reduced-sodium salt but there are also clear opportunities to take actions that would increase uptake.

Core Strategies to Increase the Uptake and Use of Potassium-Enriched Low-Sodium Salt

Excess sodium consumption and insufficient potassium intake contribute to high blood pressure and thus increase the risk of heart disease and stroke. In low-sodium salt, a portion of the sodium in salt (the amount varies, typically ranging from 10 to 50%) is replaced with minerals such as potassium chloride. Low-sodium salt may be an effective, scalable, and sustainable approach to reduce sodium and therefore reduce blood pressure and cardiovascular disease at the population level. Low-sodium salt programs have not been widely scaled up, although they have the potential to both reduce dietary sodium intake and increase dietary potassium intake. This article proposes a framework for a successful scale-up of low-sodium salt use in the home through four core strategies: availability, awareness and promotion, affordability, and advocacy. This framework identifies challenges and potential solutions within the core strategies to begin to understand the pathway to successful program implementation and evaluation of low-sodium salt use.

Availability, Formulation, Labeling, and Price of Low-sodium Salt Worldwide: Environmental Scan

Background

Regular salt is about 100% sodium chloride. Low-sodium salts have reduced sodium chloride content, most commonly through substitution with potassium chloride. Low-sodium salts have a potential role in reducing the population's sodium intake levels and blood pressure, but their availability in the global market is unknown.

Objective

The aim of this study is to assess the availability, formulation, labeling, and price of low-sodium salts currently available to consumers worldwide.

Methods

Low-sodium salts were identified through a systematic literature review, Google search, online shopping site searches, and inquiry of key informants. The keywords “salt substitute,” “low-sodium salt,” “potassium salt,” “mineral salt,” and “sodium reduced salt” in six official languages of the United Nations were used for the search. Information about the brand, formula, labeling, and price was extracted and analyzed.

Results

A total of 87 low-sodium salts were available in 47 out of 195 (24%) countries worldwide, including 28 high-income countries, 13 upper-middle-income countries, and 6 lower-middle-income countries. The proportion of sodium chloride varied from 0% (sodium-free) to 88% (as percent of weight; regular salt is 100% sodium chloride). Potassium chloride was the most frequent component with levels ranging from 0% to 100% (potassium chloride salt). A total of 43 (49%) low-sodium salts had labels with the potential health risks, and 33 (38%) had labels with the potential health benefits. The median price of low-sodium salts in high-income, upper-middle-income, and lower-middle-income countries was US $15.00/kg (IQR 6.4-22.5), US $2.70/kg (IQR 1.7-5.5), and US $2.90/kg (IQR 0.50-22.2), respectively. The price of low-sodium salts was between 1.1 and 14.6 times that of regular salts.

Conclusions

Low-sodium salts are not widely available and are commonly more expensive than regular salts. Policies that promote the availability, affordability, and labeling of low-sodium salts should increase uptake, helping populations reduce blood pressure and prevent cardiovascular diseases.

International Registered Report Identifier (IRRID)

RR2-10.1111/jch.14054

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries

PURPOSE OF REVIEW

The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs).

RECENT FINDINGS

The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.

Progress on sodium reduction in South Korea

Introduction

High dietary sodium is a leading contributor to hypertension, and hypertension is the leading underlying cause of death globally. There is a robust body of evidence supporting the health benefits of sodium reduction. Sodium intake in South Korea is high, with about half the population consuming >4000 mg/day, twice the recommended upper limit.

Methods

In 2012, South Korea implemented its National Plan to Reduce Sodium Intake, with a goal of reducing population sodium consumption by 20%, to 3900 mg/day, by 2020. The plan included five key components: (1) a consumer awareness campaign designed to change food consumption behaviours; (2) increased availability of low-sodium foods at schools and worksites; (3) increased availability of low-sodium meals in restaurants; (4) voluntary reformulation of processed foods to lower sodium content; and (5) development of low-sodium recipes for food prepared at home. Monitoring and evaluation included tracking sodium intake and sources of dietary sodium using the Korea National Health and Nutrition Examination Survey.

Results

By 2014, South Korea had reduced dietary sodium consumption among adults by 23.7% compared to a survey conducted in 2010 prior to implementation of a nationwide salt reduction campaign that used this comprehensive, multipronged approach. The reductions in sodium intake were accompanied by reductions in population blood pressure and hypertension prevalence. Although causal associations between the sodium reduction programme and reduced sodium intake cannot be made, the declines occurred with the introduction of the programme.

Conclusion

Multicomponent interventions have great potential to reduce population sodium intake. Lessons learnt from South Korea could be applied to other countries and are likely very relevant to other Asian countries with similar food sources and consumption profiles.

Dietary Sources of Plasma trans Fatty Acids among Adults in the United States: NHANES 2009-2010

BACKGROUND

Intake of trans fatty acids (TFAs) increases LDL cholesterol, decreases HDL cholesterol, and increases the risk of heart disease morbidity and mortality. Many food products potentially contain industrially produced or ruminant TFAs. However, little is known about the dietary sources of plasma TFA concentrations.

OBJECTIVE

The objective of this study was to examine associations between foods consumed and plasma TFA concentrations using 24-h dietary recall data and plasma TFA measures among adults aged ≥20 y who participated in the NHANES 2009-2010 in the United States.

METHODS

Over 4400 food products in the dietary interview data were categorized into 32 food and beverage groups/subgroups. Four major plasma TFAs (palmitelaidic acid, elaidic acid, vaccenic acid, linolelaidic acid) and the sum of the 4 TFAs (sumTFAs) were analyzed using GC-MS. Multivariable linear regression analyses were conducted to identify associations of plasma TFAs with all 32 food and beverage groups/subgroups, controlling for the potential confounding effects of 11 demographic, socioeconomic, behavioral, lifestyle, and health-related variables.

RESULTS

Consumption of the following food groups/subgroups was significantly associated with elevated plasma TFA concentrations: cream substitutes (P < 0.001 for palmitelaidic acid, elaidic acid, vaccenic acid, and sumTFAs); cakes, cookies, pastries, and pies (P < 0.001 for elaidic acid, vaccenic acid, and sumTFAs; P < 0.05 for linolelaidic acid); milk and milk desserts (P < 0.01 for palmitelaidic acid and vaccenic acid; P < 0.05 for linolelaidic acid and sumTFAs); beef/veal, lamb/goat, and venison/deer (P < 0.01 for vaccenic acid; P < 0.05 for sumTFAs); and butters (P < 0.001 for palmitelaidic acid and vaccenic acid; P < 0.05 for sumTFAs).

CONCLUSIONS

The findings suggest that the above 5 food groups/subgroups could be the main dietary sources of plasma TFAs among adults in the United States in 2009-2010.

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 cost-effectiveness of hypertension management in low-income and middle-income countries: a review

Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes.

Priority Actions to Advance Population Sodium Reduction

High sodium intake is estimated to cause approximately 3 million deaths per year worldwide. The estimated average sodium intake of 3.95 g/day far exceeds the recommended intake. Population sodium reduction should be a global priority, while simultaneously ensuring universal salt iodization. This article identifies high priority strategies that address major sources of sodium: added to packaged food, added to food consumed outside the home, and added in the home. To be included, strategies needed to be scalable and sustainable, have large benefit, and applicable to one of four measures of effectiveness: (1) Rigorously evaluated with demonstrated success in reducing sodium; (2) suggestive evidence from lower quality evaluations or modeling; (3) rigorous evaluations of similar interventions not specifically for sodium reduction; or (4) an innovative approach for sources of sodium that are not sufficiently addressed by an existing strategy. We identified seven priority interventions. Four target packaged food: front-of-pack labeling, packaged food reformulation targets, regulating food marketing to children, and taxes on high sodium foods. One targets food consumed outside the home: food procurement policies for public institutions. Two target sodium added at home: mass media campaigns and population uptake of low-sodium salt. In conclusion, governments have many tools to save lives by reducing population sodium intake.

Reducing Premature Mortality from Cardiovascular and Other Non-Communicable Diseases by One Third: Achieving Sustainable Development Goal Indicator 3.4.1

Non-communicable diseases (NCDs) are the world's leading causes of death and disability, with cardiovascular disease (CVD) accounting for half of NCD deaths. An ambitious global target established by the United Nations Sustainable Development Goals - indicator 3.4.1 - aims to reduce the risk of premature death among people aged 30-69 years from CVD, cancer, diabetes, and chronic lung disease by one third by 2030. This article reviews the science and practice informing what is required to achieve this target, identifying seven interventions that can accelerate progress: 1) tobacco control; 2) treatment to reduce cardiovascular risk; 3) reduction of dietary sodium; 4) reduction of household air pollution; 5) elimination of artificial trans fat; 6) reduction of alcohol use; and 7) prevention, detection, and treatment of cancers. Achieving the target is possible - there has already been progress in some areas, particularly related to CVD reduction - but only if there is faster, more concerted action.

Potassium-Enriched Salt Substitutes as a Means to Lower Blood Pressure: Benefits and Risks

Use of salt substitutes containing potassium chloride is a potential strategy to reduce sodium intake, increase potassium intake, and thereby lower blood pressure and prevent the adverse consequences of high blood pressure. In this review, we describe the rationale for using potassium-enriched salt substitutes, summarize current evidence on the benefits and risks of potassium-enriched salt substitutes and discuss the implications of using potassium-enriched salt substitutes as a strategy to lower blood pressure. A benefit of salt substitutes that contain potassium chloride is the expected reduction in dietary sodium intake at the population level because of reformulation of manufactured foods or replacement of sodium chloride added to food during home cooking or at the dining table. There is empirical evidence that replacement of sodium chloride with potassium-enriched salt substitutes lowers systolic and diastolic blood pressure (average net Δ [95% CI] in mm Hg: -5.58 [-7.08 to -4.09] and -2.88 [-3.93 to -1.83], respectively). The risks of potassium-enriched salt substitutes include a possible increased risk of hyperkalemia and its principal adverse consequences: arrhythmias and sudden cardiac death, especially in people with conditions that impair potassium excretion such as chronic kidney disease. There is insufficient evidence regarding the effects of potassium-enriched salt substitutes on the occurrence of hyperkalemia. There is a need for additional empirical research on the effect of increasing dietary potassium and potassium-enriched salt substitutes on serum potassium levels and the risk of hyperkalemia, as well as for robust estimation of the population-wide impact of replacing sodium chloride with potassium-enriched salt substitutes.

Global Surveillance of trans-Fatty Acids

Trans-fatty acid (TFA) intake can increase the risk of coronary heart disease (CHD) morbidity and mortality and all-cause mortality. Industrially produced TFAs and ruminant TFAs are the major sources in foods. TFA intake and TFA-attributed CHD mortality vary widely worldwide. Excessive TFA intake is a health threat in high-income countries; however, it is also a threat in low- and middle-income countries (LMICs). Data on TFA intake are scarce in many LMICs and an urgent need exists to monitor TFAs globally. We reviewed global TFA intake and TFA-attributed CHD mortality and current progress toward policy or regulation on elimination of industrially produced TFAs in foods worldwide. Human biological tissues can be used as biomarkers of TFAs because they reflect actual intake from various foods. Measuring blood TFA levels is a direct and reliable method to quantify TFA intake.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The International Consortium for Quality Research on Dietary Sodium/Salt (TRUE) position statement on the use of 24-hour, spot, and short duration (<24 hours) timed urine collections to assess dietary sodium intake

The International Consortium for Quality Research on Dietary Sodium/Salt (TRUE) is a coalition of intentional and national health and scientific organizations formed because of concerns low-quality research methods were creating controversy regarding dietary salt reduction. One of the main sources of controversy is believed related to errors in estimating sodium intake with urine studies. The recommendations and positions in this manuscript were generated following a series of systematic reviews and analyses by experts in hypertension, nutrition, statistics, and dietary sodium. To assess the population's current 24-hour dietary sodium ingestion, single complete 24-hour urine samples, collected over a series of days from a representative population sample, were recommended. To accurately estimate usual dietary sodium at the individual level, at least 3 non-consecutive complete 24-hour urine collections obtained over a series of days that reflect the usual short-term variations in dietary pattern were recommended. Multiple 24-hour urine collections over several years were recommended to estimate an individual's usual long-term sodium intake. The role of single spot or short duration timed urine collections in assessing population average sodium intake requires more research. Single or multiple spot or short duration timed urine collections are not recommended for assessing an individual's sodium intake especially in relationship to health outcomes. The recommendations should be applied by scientific review committees, granting agencies, editors and journal reviewers, investigators, policymakers, and those developing and creating dietary sodium recommendations. Low-quality research on dietary sodium/salt should not be funded, conducted, or published.

Healthy Food Availability Among Food Sources in Rural Maryland Counties

Most studies examining the association of the food environment and health outcomes have focused on urban settings. However, rural adults and children have high rates of obesity, which may be related to their food environments. This study examines the food environment in 7 rural counties in Maryland. A cross-sectional study was conducted at 244 retail food stores from 2012 to 2013. Data on store-level characteristics were collected and a healthy food availability index (HFAI) ranging from 0 to 31 points was calculated for each store. Convenience stores (18.9%) and other nontraditional stores (16.8%) were the most common store types, and box stores were the least (4.9%). Supermarkets had the highest mean HFAI (24.8), whereas gas stations (8.7) had the lowest; convenience stores were also low (11.1). In rural Maryland, the most common food source types have low healthy food availability, and nontraditional food sources are an important part of the food environment.

Baltimore City Stores Increased The Availability Of Healthy Food After WIC Policy Change

As part of a 2009 revision to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, the Department of Agriculture required WIC-authorized stores to stock additional varieties of healthy food. The long-term effects of this policy on access to healthy food are unknown. Using surveys conducted in 118 Baltimore City, Maryland, food stores in 2006 and 2012, we examined associations of the change in healthy food availability with store type, neighborhood demographics, and the 2009 WIC policy change. Overall, healthy food availability improved significantly between 2006 and 2012, with the greatest increases in corner stores and in census tracts with more than 60 percent black residents. On an 11-point scale measuring availability of fruit (3 points), vegetables (4 points), bread (2 points), and milk (2 points), the WIC policy change was associated with a 0.72-point increase in WIC-relevant healthy food availability, while joining WIC was associated with a 0.99-point increase. Stores that carry a limited variety of food items may be more receptive to stocking healthier food than previously thought, particularly within neighborhoods with a majority of black residents. Policies targeting healthy food availability have the potential to increase availability and decrease health disparities.

Spousal Influence on Physical Activity in Middle-Aged and Older Adults: The ARIC Study

Low physical activity levels are a public health concern. Few studies have assessed the concordance of physical activity change among spouses. We studied this concordance during a 6-year period (baseline: 1987-1989; follow-up: 1993-1995) in 3,261 spousal pairs from the US-based Atherosclerosis Risk in Communities (ARIC) Study. Linear regression was used to examine the association between change in individuals' sport/exercise and leisure physical activity indices (ranging from 1 (low) to 5 (high)) and change in his or her spouse's indices. The association between individual and spousal changes in meeting physical activity recommendations was assessed with logistic regression. Individual changes in the sport/exercise and leisure indices were positively associated with spousal changes. For every standard deviation increase in their wives' sport/exercise index, men's exercise index increased by 0.09 (95% confidence interval: 0.05, 0.12) standard deviation; for every standard deviation increase in their wives' leisure index, men's leisure index increased by 0.08 standard deviation. Results were similar for women. Individuals had higher odds of meeting physical activity recommendations if their spouse met recommendations at both visits or just follow-up. In conclusion, changes in an individual's physical activity are positively associated with changes in his or her spouse's physical activity. Physical activity promotion efforts should consider targeting couples.

Changes in Body Mass Index and Obesity Risk in Married Couples Over 25 Years: The ARIC Cohort Study

Married couples might be an appropriate target for obesity prevention interventions. In the present study, we aimed to evaluate whether an individual's risk of obesity is associated with spousal risk of obesity and whether an individual's change in body mass index (BMI; weight in kilograms divided by height in meters squared) is associated with spousal BMI change. We analyzed data from 3,889 spouse pairs in the Atherosclerosis Risk in Communities Study cohort who were sampled at ages 45-65 years from 1986 to 1989 and followed for up to 25 years. We estimated hazard ratios for incident obesity by whether spouses remained nonobese, became obese, remained obese, or became nonobese. We estimated the association of participants' BMI changes with concurrent spousal BMI changes using linear mixed models. Analyses were stratified by sex. At baseline, 22.6% of men and 24.7% of women were obese. Nonobese participants whose spouses became obese were more likely to become obese themselves (for men, hazard ratio = 1.78, 95% confidence interval: 1.30, 2.43; for women, hazard ratio = 1.89, 95% confidence interval: 1.39, 2.57). With each 1-unit increase in spousal BMI change, women's BMI change increased by 0.15 (95% confidence interval: 0.13, 0.18) and men's BMI change increased by 0.10 (95% confidence interval: 0.09, 0.12). Having a spouse become obese nearly doubles one's risk of becoming obese. Future research should consider exploring the efficacy of obesity prevention interventions in couples.

Effects of a behavioral intervention that emphasizes spices and herbs on adherence to recommended sodium intake: results of the SPICE randomized clinical trial

BACKGROUND

For decades, dietary sodium intake in the United States has remained high, and few studies have examined strategies for maintaining recommended intakes.

OBJECTIVE

We examined the effects of a behavioral intervention, which emphasized spices and herbs, on the maintenance of sodium intake at the recommended intake of 1500 mg/d in individuals to whom the US Dietary Guidelines for Americans apply.

DESIGN

We conducted a 2-phase study that included adults ≥18 y of age for whom Dietary Guidelines for Americans recommends 1500 mg Na/d. The study was conducted in Baltimore, Maryland, from 2012 to 2014. In phase 1, 55 individuals consumed a low-sodium diet for 4 wk. Participants were provided all foods, snacks, and calorie-containing drinks. In phase 2, 40 participants from phase 1 were randomly assigned to either a behavioral intervention to reduce sodium intake (n = 20) or a self-directed control group (n = 20) for 20 wk. The primary study outcome was the change in mean 24-h urinary sodium excretion during phase 2. Linear regression analyses were used to determine intervention effects on urinary sodium excretion.

RESULTS

Participant characteristics were as follows: women: 65%; African American: 88%; hypertension: 63%; diabetes: 18%; mean age: 61 y; and mean body mass index (in kg/m(2)): 30. At the end of phase 2, mean 24-h sodium excretion was lower in the behavioral intervention than in the self-directed group (mean difference: -956.8 mg/d; 95% CI: -1538.7, -374.9 mg/d) after sodium intake at screening was controlled for (P = 0.002). These findings persisted in sensitivity analyses that excluded potentially incomplete urine collections [Mage's equation mean difference: -1090 mg/d (P = 0.001); Joosens' equation mean difference: -796 mg/d (P = 0.04)].

CONCLUSIONS

A multifactorial behavioral intervention emphasizing spices and herbs significantly reduced sodium intake. Because of the ubiquity of sodium in the US food supply, multilevel strategies addressing individual behaviors and the food supply are needed to improve adherence to recommendations. This trial was registered at clinicaltrials.gov as NCT01615159.

The relationship of the local food environment with obesity: A systematic review of methods, study quality, and results

OBJECTIVE

To examine the relationship between local food environments and obesity and assess the quality of studies reviewed.

METHODS

Systematic keyword searches identified studies from US and Canada that assessed the relationship of obesity to local food environments. We applied a quality metric based on design, exposure and outcome measurement, and analysis.

RESULTS

We identified 71 studies representing 65 cohorts. Overall, study quality was low; 60 studies were cross-sectional. Associations between food outlet availability and obesity were predominantly null. Among non-null associations, we saw a trend toward inverse associations between supermarket availability and obesity (22 negative, 4 positive, 67 null) and direct associations between fast food and obesity (29 positive, 6 negative, 71 null) in adults. We saw direct associations between fast food availability and obesity in lower income children (12 positive, 7 null). Indices including multiple food outlets were most consistently associated with obesity in adults (18 expected, 1 not expected, 17 null). Limiting to higher quality studies did not affect results.

CONCLUSIONS

Despite the large number of studies, we found limited evidence for associations between local food environments and obesity. The predominantly null associations should be interpreted cautiously due to the low quality of available studies.

The association of spousal smoking status with the ability to quit smoking: the Atherosclerosis Risk in Communities Study

Smoking is the leading cause of preventable death in the United States. Studies have shown that smoking status tends to be concordant within spouse pairs. This study aimed to estimate the association of spousal smoking status with quitting smoking in US adults. We analyzed data from 4,500 spouse pairs aged 45-64 years from the Atherosclerosis Risk in Communities Study cohort, sampled from 1986 to 1989 from 4 US communities and followed up every 3 years for a total of 9 years. Logistic regression with generalized estimating equations was used to calculate the odds ratio of quitting smoking given that one's spouse is a former smoker or a current smoker compared to a never smoker. Among men and women, being married to a current smoker decreased the odds of quitting smoking (for men, odds ratio (OR) = 0.37, 95% confidence interval (CI): 0.29, 0.46; for women, OR = 0.54, 95% CI: 0.43, 0.68). Among women only, being married to a former smoker increased the odds of quitting smoking (OR = 1.26, 95% CI: 1.04, 1.53). In conclusion, spouses of current smokers are less likely to quit, whereas women married to former smokers are more likely to quit. Smoking cessation programs and clinical advice should consider targeting couples rather than individuals.

Methodological Issues in Cohort Studies That Relate Sodium Intake to Cardiovascular Disease Outcomes

Background—

The results of cohort studies relating sodium (Na) intake to blood pressure–related cardiovascular disease (CVD) are inconsistent. To understand whether methodological issues account for the inconsistency, we reviewed the quality of these studies.

Methods and Results—

We reviewed cohort studies that examined the association between Na and CVD. We then identified methodological issues with greatest potential to alter the direction of association (reverse causality, systematic error in Na assessment), some potential to alter the direction of association (residual confounding, inadequate follow-up), and the potential to yield false null results (random error in Na assessment, insufficient power). We included 26 studies with 31 independent analyses. Of these, 13 found direct associations between Na and CVD, 8 found inverse associations, 2 found J-shaped associations, and 8 found null associations only. On average there were 3 to 4 methodological issues per study. Issues with greater potential to alter the direction of association were present in all but 1 of the 26 studies (systematic error, 22; reverse causality, 16). Issues with lesser potential to alter the direction of association were present in 18 studies, whereas those with potential to yield false null results were present in 23.

Conclusions—

Methodological issues may account for the inconsistent findings in currently available observational studies relating Na to CVD. Until well-designed cohort studies in the general population are available, it remains appropriate to base Na guidelines on the robust body of evidence linking Na with elevated blood pressure and the few existing general population trials of the effects of Na reduction on CVD.

Strategies to reduce dietary sodium intake

OPINION STATEMENT

Excess sodium intake has an important, if not predominant, role in the pathogenesis of elevated blood pressure, one of the most important modifiable determinants of cardiovascular disease (CVD). In the United States, almost 80 % of sodium in the diet comes from packaged and restaurant foods. Given the current food environment, educational efforts such as clinician counseling are useful, but a comprehensive public health approach is necessary to achieve meaningful reductions in sodium intake. A successful approach includes several key strategies, which together will both promote positive decisions by individuals and change the context in which they make those decisions. The strategies include 1) public education, 2) individual dietary counseling, 3) food labeling, 4) coordinated and voluntary industry sodium reduction, 5) government and private sector food procurement policies, and 6) FDA regulations, as recommended by the Institute of Medicine, to modify sodium's generally regarded as safe (GRAS) status. Population-wide reduction in sodium intake has the potential to substantially reduce the public burden of preventable CVD and reduce health care costs.

Population-wide sodium reduction: the bumpy road from evidence to policy

Elevated blood pressure is a highly prevalent condition that is etiologically related to coronary heart disease and stroke, two of the leading causes of morbidity and mortality throughout the world. Excess salt (sodium chloride) intake is a major determinant of elevated blood pressure. In this article, we discuss the scientific rationale for population-wide salt reduction, the types and strength of available evidence, policy-making on dietary salt intake in the United States and other countries, and the role and impact of key stakeholders. We highlight a number of lessons learned, many of which are germane to policy development in other domains.

Change in trans fatty acid content of fast-food purchases associated with New York City's restaurant regulation: a pre-post study

BACKGROUND

Dietary trans fat increases risk for coronary heart disease. In 2006, New York City (NYC) passed the first regulation in the United States restricting trans fat use in restaurants.

OBJECTIVE

To assess the effect of the NYC regulation on the trans and saturated fat content of fast-food purchases.

DESIGN

Cross-sectional study that included purchase receipts matched to available nutritional information and brief surveys of adult lunchtime restaurant customers conducted in 2007 and 2009, before and after implementation of the regulation.

SETTING

168 randomly selected NYC restaurant locations of 11 fast-food chains.

PARTICIPANTS

Adult restaurant customers interviewed in 2007 and 2009.

MEASUREMENTS

Change in mean grams of trans fat, saturated fat, trans plus saturated fat, and trans fat per 1000 kcal per purchase, overall and by chain type.

RESULTS

The final sample included 6969 purchases in 2007 and 7885 purchases in 2009. Overall, mean trans fat per purchase decreased by 2.4 g (95% CI, -2.8 to -2.0 g; P < 0.001), whereas saturated fat showed a slight increase of 0.55 g (CI, 0.1 to 1.0 g; P = 0.011). Mean trans plus saturated fat content decreased by 1.9 g overall (CI, -2.5 to -1.2 g; P < 0.001). Mean trans fat per 1000 kcal decreased by 2.7 g per 1000 kcal (CI, -3.1 to -2.3 g per 1000 kcal; P < 0.001). Purchases with zero grams of trans fat increased from 32% to 59%. In a multivariate analysis, the poverty rate of the neighborhood in which the restaurant was located was not associated with changes.

LIMITATION

Fast-food restaurants that were included may not be representative of all NYC restaurants.

CONCLUSION

The introduction of a local restaurant regulation was associated with a substantial and statistically significant decrease in the trans fat content of purchases at fast-food chains, without a commensurate increase in saturated fat. Restaurant patrons from high- and low-poverty neighborhoods benefited equally. However, federal regulation will be necessary to fully eliminate population exposure to industrial trans fat sources.

PRIMARY FUNDING SOURCE

City of New York and the Robert Wood Johnson Foundation Healthy Eating Research program.