Low sodium diet for gastric cancer prevention in the United States: Results of a Markov model.

BACKGROUND AND AIMS: High sodium consumption has been associated with an increased risk of gastric cancer. The mean daily sodium intake in the United States substantially exceeds the national recommended amount. The low sodium-DASH diet has been shown to decrease the risk of cardiovascular disease in the United States, but its impact on gastric cancer has not been well studied. We therefore aimed to model the impact and cost-effectiveness of the low sodium-DASH diet for gastric cancer prevention in the U.S. METHODS: A Markov cohort state-transition model was developed to simulate the impact of the low sodium-DASH diet on gastric cancer outcomes for the average 40-year-old in the United States compared to no intervention. Primary outcomes of interest were gastric cancer incidence and incremental cost-effectiveness ratios (ICER). RESULTS: Our model found that compared to the no intervention cohort, the risk of gastric cancer decreased by 24.8% for males and 21.2% for females on the low sodium-DASH diet. 27 cases and 14 cases per 10,000 individuals were prevented for males and females, respectively, in the intervention group. The ICER for the low sodium-DASH diet strategy was $287,726 for males and $423,878 for females compared to the no intervention strategy. CONCLUSIONS: Using a Markov model of gastric cancer risk, we found that adherence to a low sodium-DASH diet could decrease the risk of gastric cancer. This intervention was not cost-effective due to the high cost of a low sodium-DASH accordant diet, but significantly improved for high-risk populations and when the cost of the diet became slightly more affordable.

Quantifying the impact of the Public Health Responsibility Deal on salt intake, cardiovascular disease and gastric cancer burdens: interrupted time series and microsimulation study.

BACKGROUND: In 2011, England introduced the Public Health Responsibility Deal (RD), a public-private partnership (PPP) which gave greater freedom to the food industry to set and monitor targets for salt intakes. We estimated the impact of the RD on trends in salt intake and associated changes in cardiovascular disease (CVD) and gastric cancer (GCa) incidence, mortality and economic costs in England from 2011-2025. METHODS: We used interrupted time series models with 24 hours' urine sample data and the IMPACTNCD microsimulation model to estimate impacts of changes in salt consumption on CVD and GCa incidence, mortality and economic impacts, as well as equity impacts. RESULTS: Between 2003 and 2010 mean salt intake was falling annually by 0.20 grams/day among men and 0.12 g/d among women (P-value for trend both < 0.001). After RD implementation in 2011, annual declines in salt intake slowed statistically significantly to 0.11 g/d among men and 0.07 g/d among women (P-values for differences in trend both P < 0.001). We estimated that the RD has been responsible for approximately 9900 (interquartile quartile range (IQR): 6700 to 13,000) additional cases of CVD and 1500 (IQR: 510 to 2300) additional cases of GCa between 2011 and 2018. If the RD continues unchanged between 2019 and 2025, approximately 26 000 (IQR: 20 000 to 31,000) additional cases of CVD and 3800 (IQR: 2200 to 5300) cases of GCa may occur. INTERPRETATION: Public-private partnerships such as the RD which lack robust and independent target setting, monitoring and enforcement are unlikely to produce optimal health gains.

Process Evaluation and Costing of a Multifaceted Population-Wide Intervention to Reduce Salt Consumption in Fiji.

This paper reports the process evaluation and costing of a national salt reduction intervention in Fiji. The population-wide intervention included engaging food industry to reduce salt in foods, strategic health communication and a hospital program. The evaluation showed a 1.4 g/day drop in salt intake from the 11.7 g/day at baseline; however, this was not statistically significant. To better understand intervention implementation, we collated data to assess intervention fidelity, reach, context and costs. Government and management changes affected intervention implementation, meaning fidelity was relatively low. There was no active mechanism for ensuring food companies adhered to the voluntary salt reduction targets. Communication activities had wide reach but most activities were one-off, meaning the overall dose was low and impact on behavior limited. Intervention costs were moderate (FJD $277,410 or $0.31 per person) but the strategy relied on multi-sector action which was not fully operationalised. The cyclone also delayed monitoring and likely impacted the results. However, 73% of people surveyed had heard about the campaign and salt reduction policies have been mainstreamed into government programs. Longer-term monitoring of salt intake is planned through future surveys and lessons from this process evaluation will be used to inform future strategies in the Pacific Islands and globally.

Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review.

OBJECTIVE: To analyse and compare the cost-effectiveness of different interventions to reduce salt consumption. DESIGN: A systematic review of published cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) was undertaken in the databases EMBASE, MEDLINE (PubMed), Cochrane and others until July 2016. Study selection was limited to CEA and CUA conducted in member countries of the Organisation for Economic Co-operation and Development (OECD) in English, German or French, without time limit. Outcomes measures were life years gained (LYG), disability-adjusted life years (DALY) and quality-adjusted life years (QALY). Relevant aspects in modelling were analysed and compared. Quality assessments were conducted using the Drummond and Jefferson/British Medical Journal checklist. SETTING: OECD member countries. SUBJECTS: Mainly adults. RESULTS: Fourteen CEA and CUA were included in the review which analysed different strategies: salt reduction or substitution in processed foods, taxes, labelling, awareness campaigns and targeted dietary advice. Fifty-nine out of sixty-two scenarios were cost-saving. The incremental cost-effectiveness ratio in international dollars (Intl.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (303 900 Intl.$/DALY). However, only six studies analysed cost-effectiveness from a societal perspective and quality assessments showed flaws in conducting and a lack of transparency in reporting. CONCLUSIONS: A population-wide salt reduction could be cost-effective in prevention of hypertension and CVD in OECD member countries. However, comparability between study results is limited due to differences in modelling, applied perspectives and considered data.

How expensive is a cardioprotective diet? Analysis from the CRESSIDA study.

OBJECTIVE: To determine whether a cardioprotective dietary intervention based on UK dietary guidelines was more expensive than a conventional UK diet. DESIGN: Cost analysis of food records collected at baseline and after a 12-week dietary intervention of a cardioprotective diet v. conventional UK diet. SETTING: A randomized controlled dietary intervention study (CRESSIDA; ISRCTN 92382106) investigating the impact of following a diet consistent with UK dietary guidelines on CVD risk. SUBJECTS: Participants were healthy UK residents aged 40-70 years. A sub-sample of participants was randomly selected from those who completed the cardioprotective dietary intervention (n 20) or the conventional UK dietary intervention (n 20). RESULTS: Baseline diet costs did not differ between groups; mean daily food cost for all participants was £6·12 (sd £1·83). The intervention diets were not more expensive: at end point the mean daily cost of the cardioprotective diet was £6·43 (sd £2·05) v. the control diet which was £6·53 (sd £1·53; P=0·86). CONCLUSIONS: There was no evidence that consumption of a cardioprotective diet was more expensive than a conventional dietary pattern. Despite the perception that healthier foods are less affordable, these results suggest that cost may not be a barrier when modifying habitual intake and under tightly controlled trial conditions. The identification of specific food groups that may be a cost concern for individuals may be useful for tailoring interventions for CVD prevention for individuals and populations.

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.

The Impact of Body Image on the WTP Values for Reduced-Fat and Low-Salt Content Potato Chips among Obese and Non-Obese Consumers.

The aim of this study is to assess the influence of body image on consumers' willingness to pay (WTP) for potato chips carrying nutritional claims among obese and non-obese people. About 309 non-clinical individuals participated in a Real Choice Experiment. They were recruited by a company and grouped in: (i) non-obese with good body image; (ii) non-obese with body image dissatisfaction; (iii) obese with good body image; (iv) obese with body image dissatisfaction. Results indicate differences in consumers' willingness to pay among consumer groups. Body image dissatisfaction of normal people did not influence the WTP for healthier chips. Obese people with body image dissatisfaction were willing to pay more for healthier chips (i.e., low-salt content potato chips) than normal ones with body image dissatisfaction. Examining the role of knowledge in the light of how this could impact on body image is relevant to improve the health status of individuals and their diet. Knowledge about nutrition could improve the body image of obese people.

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.

Reducing salt in food; setting product-specific criteria aiming at a salt intake of 5 g per day.

BACKGROUND/OBJECTIVES: There is an increasing public health concern regarding high salt intake, which is generally between 9 and 12 g per day, and much higher than the 5 g recommended by World Health Organization. Several relevant sectors of the food industry are engaged in salt reduction, but it is a challenge to reduce salt in products without compromising on taste, shelf-life or expense for consumers. The objective was to develop globally applicable salt reduction criteria as guidance for product reformulation. SUBJECTS/METHODS: Two sets of product group-specific sodium criteria were developed to reduce salt levels in foods to help consumers reduce their intake towards an interim intake goal of 6 g/day, and­on the longer term­5 g/day. Data modelling using survey data from the United States, United Kingdom and Netherlands was performed to assess the potential impact on population salt intake of cross-industry food product reformulation towards these criteria. RESULTS: Modelling with 6 and 5 g/day criteria resulted in estimated reductions in population salt intake of 25 and 30% for the three countries, respectively, the latter representing an absolute decrease in the median salt intake of 1.8-2.2 g/day. CONCLUSIONS: The sodium criteria described in this paper can serve as guidance for salt reduction in foods. However, to enable achieving an intake of 5 g/day, salt reduction should not be limited to product reformulation. A multi-stakeholder approach is needed to make consumers aware of the need to reduce their salt intake. Nevertheless, dietary impact modelling shows that product reformulation by food industry has the potential to contribute substantially to salt-intake reduction.

Sodium content and labelling of processed and ultra-processed food products marketed in Brazil.

OBJECTIVE: To analyse the Na content and labelling of processed and ultra-processed food products marketed in Brazil. DESIGN: Cross-sectional study. SETTING: A large supermarket in Florianopolis, southern Brazil. SUBJECTS: Ingredient lists and Na information on nutrition labels of all processed and ultra-processed pre-prepared meals and prepared ingredients, used in lunch or dinner, available for sale in the supermarket. RESULTS: The study analysed 1416 products, distributed into seven groups and forty-one subgroups. Five products did not have Na information. Most products (58.8 %; 95 % CI 55.4, 62.2 %) had high Na content (>600 mg/100 g). In 78.0 % of the subgroups, variation in Na content was at least twofold between similar products with high and low Na levels, reaching 634-fold difference in the 'garnishes and others' subgroup. More than half of the products (52.0 %; 95 % CI 48.2, 55.6 %) had at least one Na-containing food additive. There was no relationship between the appearance of salt on the ingredients list (first to third position on the list) and a product's Na content (high, medium or low; P=0.08). CONCLUSIONS: Most food products had high Na content, with great variation between similar products, which presents new evidence for reformulation opportunities. There were inconsistencies in Na labelling, such as lack of nutritional information and incomplete ingredient descriptions. The position of salt on the ingredients list did not facilitate the identification of high-Na foods. We therefore recommend a reduction in Na in these products and a review of Brazilian legislation.

An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study.

OBJECTIVES: Dietary salt intake has been causally linked to high blood pressure and increased risk of cardiovascular events. Cardiovascular disease causes approximately 35% of total UK deaths, at an estimated annual cost of £30 billion. The World Health Organization and the National Institute for Health and Care Excellence have recommended a reduction in the intake of salt in people's diets. This study evaluated the cost-effectiveness of four population health policies to reduce dietary salt intake on an English population to prevent coronary heart disease (CHD). METHODS: The validated IMPACT CHD model was used to quantify and compare four policies: 1) Change4Life health promotion campaign, 2) front-of-pack traffic light labeling to display salt content, 3) Food Standards Agency working with the food industry to reduce salt (voluntary), and 4) mandatory reformulation to reduce salt in processed foods. The effectiveness of these policies in reducing salt intake, and hence blood pressure, was determined by systematic literature review. The model calculated the reduction in mortality associated with each policy, quantified as life-years gained over 10 years. Policy costs were calculated using evidence from published sources. Health care costs for specific CHD patient groups were estimated. Costs were compared against a "do nothing" baseline. RESULTS: All policies resulted in a life-year gain over the baseline. Change4life and labeling each gained approximately 1960 life-years, voluntary reformulation 14,560 life-years, and mandatory reformulation 19,320 life-years. Each policy appeared cost saving, with mandatory reformulation offering the largest cost saving, more than £660 million. CONCLUSIONS: All policies to reduce dietary salt intake could gain life-years and reduce health care expenditure on coronary heart disease.

The increasing burden of hypertension in Nigeria - can a dietary salt reduction strategy change the trend?

Developing countries face a dual challenge of both communicable and non-communicable disease - 80% of deaths from cardiovascular disease occur in low and middle-income countries. Hypertension ranks highest as an attributable cause of mortality in both developed and developing countries. The prevalence of hypertension is rising rapidly in Nigeria, from 11% two decades ago to about 30% in recent times. This review explores salt reduction in the diet at the population-wide level as a means of reducing the burden of hypertension in Nigeria. The evidence behind this strategy is explored, methods of how this goal was achieved in other countries are investigated and recommendations on how it could be accomplished in the Nigerian context are considered. There are suggestions that if salt reductions are effectively implemented on a population-wide basis, it will have an impact on morbidity and mortality as large as that which the provision of drains and safe water had in the 19(th) century.

Should we eat less salt?

High blood pressure is a major cardiovascular risk factor. There is overwhelming evidence that high salt consumption is a major cause of increased blood pressure. There is also a link between high salt consumption and risk of stroke, left ventricular hypertrophy, renal disease, obesity, renal stones and stomach cancer. Reducing salt consumption leads to a decrease in blood pressure and the incidence of cardiovascular disease. There are no deleterious effects associated with reducing salt consumption and it is also very cost-effective. Many organizations and state governments have issued recommendations regarding the suitable amount of salt consumption. In France, the objective is a salt consumption<8g/day in men and<6.5g/day in women and children. As 80% of consumed salt comes from manufactured products in developed countries, reduction of salt consumption requires the participation of the food industry. The other tool is consumer information and education. Salt consumption has already decreased in France in recent years, but efforts must continue.

The feasibility of achieving low-sodium intake in diets that are also nutritious, low-cost, and have familiar meal components.

OBJECTIVE: Given the importance of high sodium diets as a risk factor for disease burden (ranked 11(th) in importance in the Global Burden of Disease Study 2010), we aimed to determine the feasibility of low-sodium diets that were also low-cost, nutritious and (for some scenarios) included familiar meals. METHODS: The mathematical technique of "linear programming" was used to model eight optimized daily diets (some with uncertainty), including some diets that contained "familiar meals" for New Zealanders or were Mediterranean-, Asian- and Pacific-style diets. Data inputs included nutrients in foods, food prices and food wastage. FINDINGS: Using nutrient recommendations for men and a cost constraint of

Cost-effectiveness of interventions to reduce dietary salt intake.

OBJECTIVE: To evaluate population health benefits and cost-effectiveness of interventions for reducing salt in the diet. DESIGN: Proportional multistate life-table modelling of cardiovascular disease and health sector cost outcomes over the lifetime of the Australian population in 2003. INTERVENTIONS: The current Australian programme of incentives to the food industry for moderate reduction of salt in processed foods; a government mandate of moderate salt limits in processed foods; dietary advice for everyone at increased risk of cardiovascular disease and dietary advice for those at high risk. MAIN OUTCOME MEASURES: Costs measured in Australian dollars for the year 2003. Health outcomes measured in disability-adjusted life years (DALY) averted over the lifetime. RESULTS: Mandatory and voluntary reductions in the salt content of processed food are cost-saving interventions under all modelled scenarios of discounting, costing and cardiovascular disease risk reversal (dominant cost-effectiveness ratios). Dietary advice targeting individuals is not cost-effective under any of the modelled scenarios, even if directed at those with highest blood pressure risk only (best case median cost-effectiveness A$100 000/DALY; 95% uncertainty interval A$64 000/DALY to A$180 000/DALY). Although the current programme that relies on voluntary action by the food industry is cost-effective, the population health benefits could be 20 times greater with government legislation on moderate salt limits in processed foods. CONCLUSIONS: Programmes to encourage the food industry to reduce salt in processed foods are highly recommended for improving population health and reducing health sector spending in the long term, but regulatory action from government may be needed to achieve the potential of significant improvements in population health.

Reducing population salt intake worldwide: from evidence to implementation.

Raised blood pressure is a major cause of cardiovascular disease, responsible for 62% of stroke and 49% of coronary heart disease. There is overwhelming evidence that dietary salt is the major cause of raised blood pressure and that a reduction in salt intake lowers blood pressure, thereby, reducing blood pressure-related diseases. Several lines of evidence including ecological, population, and prospective cohort studies, as well as outcome trials, demonstrate that a reduction in salt intake is related to a lower risk of cardiovascular disease. Increasing evidence also suggests that a high salt intake may directly increase the risk of stroke, left ventricular hypertrophy, and renal disease; is associated with obesity through soft drink consumption; is related to renal stones and osteoporosis; is linked to the severity of asthma; and is probably a major cause of stomach cancer. In most developed countries, a reduction in salt intake can be achieved by a gradual and sustained reduction in the amount of salt added to foods by the food industry. In other countries where most of the salt consumed comes from salt added during cooking or from sauces, a public health campaign is needed to encourage consumers to use less salt. Several countries have already reduced salt intake. The challenge now is to spread this out to all other countries. A modest reduction in population salt intake worldwide will result in a major improvement in public health.

Infl uencia de la dieta hiposódica en el paciente hipertenso / The infl uence of the hyposodic diet in the hypertensive patient

Introducción: La hipertensión arterial es una enfermedad muy frecuente en las sociedades desarrolladas, cuya prevalencia aumenta con la edad, llegando a afectar al 50% de las personas mayores de 60 años, con graves consecuencias para la salud. Para su tratamiento, además de las medidas farmacológicas, se dispone de las llamadas medidas higiénico-dietéticas, entre las que tiene especial importancia la reducción en la ingesta total de sodio, como puso de relevancia el estudio INTERSALT en 1988. Tal es así, que actualmente está socialmente aceptado que la primera medida que se debe tomar para el control y la disminución de las cifras de presión arterial (PA) es la dieta hiposódica. Objetivo: Comprobar el efecto de la reducción de la ingesta de sodio en las cifras de PA en personas con PA sistólica ³139 mmHg y de PA diastólica ³89 mmHg. Metodología: Se diseñó un estudio de intervención, casi experimental, tipo ensayo cruzado (crossover). Se midió la disminución de la PA conseguida tras 10 días de dieta hiposódica. Para obtener una potencia en el estudio del 90% y un error alfa del5%, necesitamos al menos un tamaño muestral de 50 casos, según una toma previa de datos. Resultados: La reducción de la ingesta de sodio durante el periodo estudiado produce una disminución media de 4,76 mmHg en la PA sistólica y de 2,92 mmHg en la PA diastólica. Los resultados obtenidos son significativos (p <0,00001). Conclusiones: La dieta hiposódica reduce los niveles de PA. Hemos apreciado que un menor seguimiento en la dieta hiposódica previa se corresponde con un mayor descenso dela PA (AU)

Introduction: Arterial hypertension is a very frequent condition in developed societies. Its prevalence increases with age and it may affect 50% of those older than 60 years, with serious consequences for their health. In addition to the pharmacological measures, one may treat this sickness using the so called hygienic-dietetic measures. Among these it is especially important the reduction in the intake of sodium as shown in the INTERSALT (1998) study. Nowadays it is socially accepted that the first measure one should take in controlling and decreasing arterial pressureis a hyposodic diet. Objective: To test the effect of a reduction in the intake of sodium in the arterial pressure in several people with systolic arterial pressure greater than 139 mmHg and diastolic arterial pressure greater than 89 mmHg. Methodology: We designed a quasi-experimental intervention study of crossover type. We measured the decrease in arterial pressure attained after 10 days of a hyposodic diet. To obtain a power in the study of 90% and an alpha error of 5% we need at least a sample of 50 individuals, according to a previous data sample. Results: The reduction in the sodium intake during the period of study produces a decrease of an average of 4.76 mmHg in the systolic arterial pressure and 2.92 mmHg en the diastolic arterial pressure. The results are significant (p <0.00001). Conclusions: A hyposodic diet reduces the level of arterial pressure. We have appreciated that the effect is greater in those who had not previously followed hyposodic diet (AU)