Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil.

INTRODUCTION: Cardiovascular diseases (CVDs) represent the main cause of death among non-communicable diseases (NCDs) in Brazil, and they have a high economic impact on health systems. Most populations around the world, including Brazilians, consume excessive sodium, which increases blood pressure and the risk of CVDs. OBJECTIVE: To model the estimated deaths and costs associated with CVDs, which are mediated by increased blood pressure attributable to excessive sodium consumption in adults from the perspective of the Brazilian public health system in 2017. METHODS: We employed two macrosimulation methods, using top-down approaches and based on the same relative risks. The models estimated the mortality and costs-of-illness attributable to excessive sodium intake and mediated by hypertension for adults aged over 30 years in 2017. Direct healthcare cost data (inpatient care, outpatient care and medications) were extracted from the Ministry of Health information systems and official records. RESULTS: In 2017, an estimated 46,651 deaths from CVDs could have been prevented if the average sodium consumption had been reduced to 2 g/day in Brazil. Premature deaths related to excessive sodium consumption caused 575,172 Years of Life Lost and US$ 752.7 million in productivity losses to the economy. In the same year, the National Health System's costs of hospitalizations, outpatient care and medication for hypertension attributable to excessive sodium consumption totaled US$192.1 million. The main causes of death and costs associated with CVDs were coronary heart disease and stroke, followed by hypertensive disease, heart failure and aortic aneurysm. CONCLUSION: Excessive sodium consumption is estimated to account for 15% of deaths by CVDs and to 14% of the inpatient and outpatient costs associated with CVD. It also has high societal costs in terms of premature deaths. CVDs are a leading cause of disease and economic burden on the global, regional and country levels. As a largely preventable and treatable conditions, CVDs require the strengthening of cost-effective policies, supported by evidence, including modeling studies, to reduce the costs relating to illness borne by the Brazilian public health system and society.

Lebanese children are iodine deficient and urinary sodium and fluoride excretion are weak positive predictors of urinary iodine.

PURPOSE: To assess iodine and fluoride status among Lebanese children. METHODS: A nationally representative cross-sectional study of 6- to 10-year-old schoolchildren was conducted using multistage cluster sampling. Spot urine samples were collected from 1403 children, and urinary iodine, fluoride, creatinine and sodium levels were measured. Salt samples from markets (n = 30) were tested for iodine concentration by titration. RESULTS: Median urinary iodine concentration was 66.0 µg/l, indicating mild deficiency, and almost 75 % of Lebanese children had a urinary iodine concentration (UIC) <100 µg/l. UIC was higher among children from private schools and in areas of higher socioeconomic status. Most salt samples were fortified at levels far below the legislated requirement, and 56 % of samples contained less than 15 ppm iodine. Fluoride-to-creatinine ratio (F/Cr) was 0.250 (0.159-0.448) mg/g. There were weak positive correlations between UIC and urinary sodium (r 2 = 0.039, P value <0.001) and UIC and urinary fluoride (r 2 = 0.009, P value <0.001). CONCLUSIONS: Lebanese elementary school children are iodine deficient due to inadequately iodized salt. The weak correlation between UIC and urinary sodium suggests most dietary iodine does not come from iodized salt. The poor correlation between UIC and urinary fluoride suggests that fluoride intake is not affecting iodine metabolism. Efforts are needed in Lebanon to improve industry compliance with salt fortification through improved monitoring and enforcement of legislation.

Perspectives of the public on reducing population salt intake in Ireland.

OBJECTIVE: As countries struggle to meet the set targets for population salt intake, there have been calls for more regulated approaches to reducing dietary salt intake. However, little is known about how the public perceives various salt reduction policies; an important line of investigation given that the implementation and success of these policies often depend on public sentiment. We investigated the attitudes and beliefs of consumers towards salt reduction and their support for thirteen different government-led salt reduction policies. DESIGN: A cross-sectional online survey measured participants' knowledge, beliefs and attitudes in relation to salt reduction. SETTING: The survey was carried out with participants from the Republic of Ireland. SUBJECTS: Five hundred and one participants recruited via a market research agency completed the survey. RESULTS: We found that the vast majority of participants supported eleven of the government-led salt reduction policies, which included measures such as education, labelling and salt restriction in foods (both voluntary and regulated, across a range of settings). The two proposed fiscal policies (subsidising low-salt foods and taxing high-salt foods) received less support in comparison, with the majority of participants opposed to a tax on high-salt foods. A series of multiple regressions revealed that individual attitudes and beliefs related to health and salt were stronger predictors of support than sociodemographic factors, lifestyle or knowledge. CONCLUSIONS: The study provides an important evidence base from which policy makers may draw when making decisions on future policy steps to help achieve national salt targets.

Food Reformulation, Responsive Regulation, and "Regulatory Scaffolding": Strengthening Performance of Salt Reduction Programs in Australia and the United Kingdom.

Strategies to reduce excess salt consumption play an important role in preventing cardiovascular disease, which is the largest contributor to global mortality from non-communicable diseases. In many countries, voluntary food reformulation programs seek to reduce salt levels across selected product categories, guided by aspirational targets to be achieved progressively over time. This paper evaluates the industry-led salt reduction programs that operate in the United Kingdom and Australia. Drawing on theoretical concepts from the field of regulatory studies, we propose a step-wise or "responsive" approach that introduces regulatory "scaffolds" to progressively increase levels of government oversight and control in response to industry inaction or under-performance. Our model makes full use of the food industry's willingness to reduce salt levels in products to meet reformulation targets, but recognizes that governments remain accountable for addressing major diet-related health risks. Creative regulatory strategies can assist governments to fulfill their public health obligations, including in circumstances where there are political barriers to direct, statutory regulation of the food industry.

Drop the Salt! Assessing the impact of a public health advocacy strategy on Australian government policy on salt.

OBJECTIVE: In 2007 the Australian Division of World Action on Salt and Health (AWASH) launched a campaign to encourage the Australian government to take action to reduce population salt intake. The objective of the present research was to assess the impact of the Drop the Salt! campaign on government policy. DESIGN: A review of government activities related to salt reduction was conducted and an advocacy strategy implemented to increase government action on salt. Advocacy actions were documented and the resulting outcomes identified. An analysis of stakeholder views on the effectiveness of the advocacy strategy was also undertaken. Settings Advocacy activities were coordinated through AWASH at the George Institute for Global Health in Sydney. SUBJECTS: All relevant State and Federal government statements and actions were reviewed and thirteen stakeholders with known interests or responsibilities regarding dietary salt, including food industry, government and health organisations, were interviewed. RESULTS: Stakeholder analysis affirmed that AWASH influenced the government's agenda on salt reduction and four key outputs were attributed to the campaign: (i) the Food Regulation Standing Committee discussions on salt, (ii) the Food and Health Dialogue salt targets, (iii) National Health and Medical Research Council partnership funding and (iv) the New South Wales Premier's Forum on Fast Foods. CONCLUSIONS: While it is not possible to definitively attribute changes in government policy to one organisation, stakeholder research indicated that the AWASH campaign increased the priority of salt reduction on the government's agenda. However, a coordinated government strategy on salt reduction is still required to ensure that the potential health benefits are fully realised.

Sustainable universal salt iodization in low-income countries - time to re-think strategies?

OBJECTIVE: Sustained iodine deficiency control requires sustainable mechanisms for iodine supplementation. We aim to describe the status of salt iodation machines, salt producers' experiences and quality of salt produced in Tanzania. METHODS: Qualitative and quantitative data was collected from the factory sites, observations were made on the status of UNICEF-supplied assisted-iodation machines and convenience samples of salt from 85 salt production facilities were analysed for iodine content. RESULTS: A total of 140 salt works visited had received 72 salt iodation machines in 1990s, but had largely abandoned them due to high running and maintenance costs. Locally devised simple technology was instead being used to iodate salt. High variability of salt iodine content was found and only 7% of samples fell within the required iodation range. CONCLUSION: Although iodine content at factory level is highly variable, overall iodine supply to the population has been deemed largely sufficient. The need for perpetual iodine fortification requires reassessment of salt iodation techniques and production-monitoring systems to ensure sustainability. The emerging local technologies need evaluation as alternative approaches for sustaining universal salt iodation in low-income countries with many small-scale salt producers.

[Sodium chloride in food rations and dinners in mass catering institutions]. / Chlorek sodu w racjach pokarmowych i posilkach obiadowych wydawanych w wybranych zakladach zywienia zbiorowego.

The sodium chloride content in meals given by mass catering institution in all over country in 1988-1998 years was estimated. This study included daily food rations from 183 mass catering institution as hospitals, sanatoriums for both children and adults, boarding schools, infant schools and social welfare homes. We assessed also school dinners from 422 randomized selected schools and dinners from 55 internal and 56 surgical departments of provincial and regional hospitals in Poland. The mass of each meal was evaluated and sodium chloride content by Mohr's method was assessed. In most cases the salt content by 100 g of meal of 1000 kcal was calculated. The dinners and daily food rations analyze showed that sodium chloride content in meals was much higher than value recommended by World Health Organization (WHO). Salt amount in daily food rations of both children and adults was above 16 g. This value didn't include salt added to meals by boarders. School dinners provided about 7-10 g of salt. The average sodium chloride content in hospital dinners was about 16-20 g. In each studied group the NaCl content per 100 g of meal was similarly high and was 0.7-0.9 g. The results of this study show that meals given by mass catering institutions can increase risk of hypertension, strokes and gastric cancers because of high sodium chloride content.