Impacts of a national strategy to reduce population salt intake in England: serial cross sectional study

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

BACKGROUND

The 2017 American College of Cardiology/American Heart Association blood pressure guideline classified 31 million US adults as having stage 1 hypertension and recommended clinicians provide counseling on behavioral change to the low-risk portion of this group. However, nationwide reductions in cardiovascular disease (CVD) and associated health care expenditures achievable by nonpharmacologic therapy remain unquantified.

METHODS

We simulated interventions on a target population of US adults aged 35 to 64 years, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: that is, untreated systolic blood pressure 130 to 139 mm Hg with diastolic BP <90 mm Hg; no history of CVD, diabetes, or chronic kidney disease; and a low 10-year risk of CVD. We used meta-analyses and trials to estimate the effects of population-level behavior modification on systolic blood pressure. We assessed the extent to which restricting intervention to those in regular contact with clinicians might prevent the delivery of nonpharmacologic therapy.

RESULTS

Controlling systolic blood pressure to <130 mm Hg among the 8.8 million low-risk US adults with stage 1 hypertension could prevent 26 100 CVD events, avoid 2900 deaths, and save $1.7 billion in total direct health care costs over 10 years. Adoption of the Dietary Approaches to Stop Hypertension diet could prevent 28 000 CVD events. Other nonpharmacologic interventions could avert between 3800 and 19 500 CVD events. However, only 51% of men and 75% of women regularly interacted with clinicians for counseling opportunities.

CONCLUSIONS

Among low-risk adults with stage 1 hypertension, substantial benefits to cardiovascular health could be achieved through public policy that promotes the adoption of nonpharmacologic therapy.

Adding salt to foods and risk of psoriasis: A prospective cohort study

BACKGROUND

High salt intake may play a critical role in the etiology of psoriasis. Yet, evidence on the association of high salt intake with risk of psoriasis is limited.

OBJECTIVE

To estimate the association between frequency of adding salt to foods and risk of psoriasis.

METHODS

We conducted a prospective cohort study of 433,788 participants from the UK Biobank. Hazard ratios (HRs) and their 95 % confidence intervals (CIs) for risk of psoriasis in relation to frequency of adding salt to foods were estimated using multivariable Cox proportional hazards models. We further evaluated the joint association of adding salt to foods and genetic susceptibility with risk of psoriasis. We conducted a mediation analysis to assess how much of the effect of adding salt to foods on risk of psoriasis was mediated through several selected mediators.

RESULTS

During a median of 14.0 years of follow-up, 4279 incident cases of psoriasis were identified. In the multivariable-adjusted model, a higher frequency of adding salt to foods was significantly associated with an increased risk of psoriasis ("always" versus "never/rarely" adding salt to foods, HR = 1.25, 95 % CI: 1.10, 1.41). The observed positive association was generally similar across subgroups. In the joint association analysis, we observed that participants with a high genetic risk (above the second tertile) and the highest frequency of adding salt to foods experienced 149 % higher risk of psoriasis, when compared with participants with a low genetic risk (below the first tertile) and the lowest frequency of adding salt to foods (HR = 2.49, 95 % CI: 2.05, 3.02). Mediation analysis revealed that 1.8 %-3.2 % of the positive association between frequency of adding salt and risk of psoriasis was statistically significantly mediated by obesity and inflammatory biomarkers such as C-reactive protein and systemic immune-inflammation index (all P values < 0.004).

CONCLUSIONS

Our study demonstrated a positive association between frequency of adding salt to foods and risk of psoriasis. The positive association was independent of multiple other risk factors, and may be partially mediated through obesity and inflammation.

Projected Impact of Nonpharmacologic Management of Stage 1 Hypertension Among Lower-Risk US Adults

Background

The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines newly classified 31 million US adults as having stage 1 hypertension. The ACC/AHA guidelines recommend behavioral change without pharmacology for the low-risk portion of this group. However, the nationwide reduction in cardiovascular disease (CVD) and associated healthcare expenditures achievable by evidence-based dietary improvements, sustained weight loss, adequate physical activity, and alcohol moderation remain unquantified. We estimated the effect of systolic BP (SBP) control and behavioral changes on 10-year CVD outcomes and costs.

Methods

We used the CVD Policy Model to simulate CVD events, mortality, and healthcare costs among US adults aged 35-64. We simulated interventions on a target population, identified from the 2015-2018 National Health and Nutrition Examination Survey, with low-risk stage 1 systolic hypertension: defined as untreated SBP 130-139 mmHg and diastolic BP <90 mmHg; no history of CVD, diabetes, or chronic kidney disease; and low 10-year risk of CVD. We used published meta-analyses and trials to estimate the effects of behavior modification on SBP. We assessed the extent to which intermittent healthcare utilization or partial uptake of nonpharmacologic therapy would decrease CVD events prevented.

Results

Controlling SBP to <130 mmHg among the estimated 8.8 million U.S. adults (51% women) in the target population could prevent 26,100 CVD events, avoid 2,900 deaths, and save $1.6 billion in healthcare costs over 10 years. The Dietary Approaches to Stop Hypertension (DASH) diet could prevent 16,000 CVD events among men and 12,000 among women over a decade. Other nonpharmacologic interventions could avert between 3,700 and 19,500 CVD events. However, only 5.5 million (61%) of the target population regularly utilized healthcare where recommended clinician counseling could occur.

Conclusions

As only two-thirds of U.S. adults with Stage 1 hypertension regularly receive medical care, substantial benefits to cardiovascular health and associated costs may only stem from policies that promote widespread adoption and sustained adherence of nonpharmacologic therapy. Future work should quantify the population-level costs, benefits, and efficacy of improving the food system and local infrastructure on health behavior change.

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

OBJECTIVE

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

DESIGN

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

SETTINGS

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Population-level salt intake in the WHO European Region in 2022: a systematic review

OBJECTIVE

The WHO recommends that adults consume less than 5 g of salt per day to reduce the risk of CVD. This study aims to examine the average population daily salt intake in the fifty-three Member States of the WHO European Region.

DESIGN

A systematic review was conducted to examine the most up-to-date salt intake data for adults published between 2000 and 2022. Data were obtained from peer-reviewed and grey literature, WHO surveys and studies, as well as from national and global experts.

SETTING

The fifty-three Member States of the WHO European Region.

PARTICIPANTS

People aged 12 years or more.

RESULTS

We identified fifty studies published between 2010 and 2021. Most countries in the WHO European Region (n 52, 98 %) reported salt intake above WHO recommended maximum levels. In almost all countries (n 52, 98 %), men consume more salt than women, ranging between 5·39 and 18·51 g for men and 4·27 and 16·14 g for women. Generally, Western and Northern European countries have the lowest average salt intake, whilst Eastern European and Central Asian countries have the highest average. Forty-two percentage of the fifty-three countries (n 22) measured salt intake using 24 h urinary collection, considered the gold standard method.

CONCLUSIONS

This study found that salt intakes in the WHO European Region are significantly above WHO recommended levels. Most Member States of the Region have conducted some form of population salt intake. However, methodologies to estimate salt intake are highly disparate and underestimations are very likely.

Public health impact of antihypertensive medication use on arterial blood pressure: A pooled cross-sectional analysis of population health surveys

The early initiation of antihypertensive drug therapy is conceived as one of the most important public health interventions addressing cardiovascular risk in the population. However, the actual contribution of this public health intervention to reduce blood pressure (BP) at the population level is largely unknown. Hence, the aim of the present investigation is to estimate the potential public health effects of the use of antihypertensive medication on BP in the population aged 16 and older. Data from three population health surveys periodically conducted in the United States, England, and Scotland are analysed (N = 362,275). The secular trends of BP measurements and the potential public health impact of the use of antihypertensive medications on BP over time are analysed in a series of linear mixed models. Between 1992 and 2019, a secular trend of decreasing systolic and diastolic BP occurred (-16.24 99% CI [-16.80; -15.68] and -3.08 99% CI [-3.36; -2.80] mmHg, respectively). The potential public health impact of the use of antihypertensive medications in the period 1992-2019 on systolic BP was estimated to lie between -8.56 99% CI [-8.34; -8.77] and -8.68 99% CI [-8.33; -9.03] mmHg. Average reduction of diastolic BP was in the range of -5.56 99% CI [-5.71; -5.42] and -6.55 99% CI [-6.78; -6.32] mmHg. The observed changes in the distribution of BP measurements over time were found to be more strongly related to secular trends affecting the whole populations, rather than to increases in the proportion of individuals taking antihypertensive medications.

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

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

Frequency of adding salt at the table and risk of incident cardiovascular disease and all-cause mortality: a prospective cohort study

BACKGROUND

Adding salt at the table is a prevalent eating habit, but its long-term relationship with cardiovascular disease (CVD) and all-cause mortality remains unclear. We evaluated the associations of adding salt at the table with the risk of incident CVD and all-cause mortality.

METHODS

Among 413,109 middle- and old-aged adults without cancer or CVD, all participants reported the frequency of adding salt at the table at baseline. The associations between adding salt at the table and incident CVD (the composite endpoint of coronary heart disease, stroke, heart failure, and CVD deaths) and all-cause mortality were investigated using Cox proportional hazards models.

RESULTS

Of the study population, the mean age was 55.8 years and 45.5% were men; 44.4% reported adding salt at the table; 4.8% reported always adding salt at the table. During a median follow-up of 12 years, there were 37,091 incident CVD cases and 21,293 all-cause deaths. After adjustment for demographic, lifestyle, and cardiometabolic risk factors, the multivariable-adjusted hazard ratios (HRs) for participants who always added salt at the table versus never/rarely added salt at the table were 1.21 (95% confidence interval [CI]: 1.16-1.26) for CVD, 1.19 (95%CI: 1.05-1.35) for CVD mortality, and 1.22 (95%CI: 1.16-1.29) for all-cause mortality, respectively.

CONCLUSIONS

In this prospective cohort study, a higher frequency of adding salt at the table was associated with a greater risk of incident CVD and mortality. Our findings support the benefits of restricting the habit of adding salt at the table in promoting cardiovascular health.

Mechanism-based strategies to prevent salt sensitivity and salt-induced hypertension

High-salt diets are a major cause of hypertension and cardiovascular (CV) disease. Many governments are interested in using food salt reduction programs to reduce the risk for salt-induced increases in blood pressure and CV events. It is assumed that reducing the salt concentration of processed foods will substantially reduce mean salt intake in the general population. However, contrary to expectations, reducing the sodium density of nearly all foods consumed in England by 21% had little or no effect on salt intake in the general population. This may be due to the fact that in England, as in other countries including the U.S.A., mean salt intake is already close to the lower normal physiologic limit for mean salt intake of free-living populations. Thus, mechanism-based strategies for preventing salt-induced increases in blood pressure that do not solely depend on reducing salt intake merit attention. It is now recognized that the initiation of salt-induced increases in blood pressure often involves a combination of normal increases in sodium balance, blood volume and cardiac output together with abnormal vascular resistance responses to increased salt intake. Therefore, preventing either the normal increases in sodium balance and cardiac output, or the abnormal vascular resistance responses to salt, can prevent salt-induced increases in blood pressure. Suboptimal nutrient intake is a common cause of the hemodynamic disturbances mediating salt-induced hypertension. Accordingly, efforts to identify and correct the nutrient deficiencies that promote salt sensitivity hold promise for decreasing population risk of salt-induced hypertension without requiring reductions in salt intake.

Comorbidities and outcomes in South Asian individuals with chronic kidney disease: an observational primary care cohort

BACKGROUND

South Asian (SA) individuals are more likely to develop end-stage renal disease (ESRD), but how chronic kidney disease (CKD) differs in relation to demographics, comorbidities and outcomes has not been studied. We aimed to study differences in SA individuals with CKD compared with White individuals.

METHODS

This was an observational CKD cohort comparing SA with White individuals. Inclusion criteria were ≥18 years of age and two or more Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFRs <60 mL/min/1.73 m2 >3 months apart. Individuals with ESRD at baseline were excluded. Baseline characteristics, including eGFR formulae [CKD-EPI and CKD-EPI-Pakistan (CKD-EPI-PK)], were compared. Analysis using competing risk regression for cardiovascular (CV) and ESRD events and Cox proportional hazard model for mortality was performed.

RESULTS

From an adult population of 277 248 individuals, 17 248 individuals had CKD, of whom 1990 (11.5%) were of SA ethnicity. Age-adjusted prevalence of CKD was similar between ethnicities. SA individuals were more likely to be male, younger and socioeconomically deprived, and to have diabetes mellitus, CV disease and advanced CKD. Mean CKD-EPI-PK eGFR was 6.5 mL/min/1.73 m2 lower (41.1 versus 47.6, 95% confidence interval for difference 6.47-6.56) than for CKD-EPI. During 5 years of follow-up, 5109 (29.6%) individuals died, 2072 (12.0%) had a CV and 156 (0.90%) an ESRD event. Risk for SA individuals was higher for ESRD, similar to CV events and lower for mortality. Each 1 mL/min/1.73 m2 decrease in CKD-EPI-PK was associated with a 13.1% increased ESRD risk (adjusted subdistribution hazard ratio 0.869, 95% confidence interval 0.841-0.898).

CONCLUSIONS

SA individuals with CKD were younger and had more advanced disease than White individuals. Risk of ESRD was higher and CKD-EPI-PK was associated with ESRD risk in SA individuals. Specific CKD interventions, including the use of CKD-EPI-PK, should be considered in SA populations.

Contribution of reformulation, product renewal, and changes in consumer behavior to the reduction of salt intakes in the UK population between 2008/2009 and 2016/2017

BACKGROUND

The UK salt reduction program started in 2003, consisting of education campaigns to raise awareness about the risks associated with a high-salt diet and of a reformulation strategy for food manufacturers. This program is often cited as an example of a successful public health program.

OBJECTIVES

This study aimed to assess: 1) the impacts of changes in food composition and changes in consumer behavior on sodium intakes; and 2) whether changes were similar across socioeconomic groups.

METHODS

Food intakes for the UK population were derived from food diaries in the UK National Diet and Nutrition Survey for 2008/09 (year 1; n = 1334) and 2016/17 (year 9; n = 995). Year-specific sodium densities of foods were used to calculate the average sodium density of all food and beverage consumed. Changes in sodium density between the 2 years were explained by changes in food composition (change in sodium density of products) and/or changes in behavior (type and quantity of food consumed) using a decomposition approach.

RESULTS

The program was linked to a 16% (95% CI: -21% to -12%) decrease in sodium intake between years 1 and 9, while the sodium density of foods consumed decreased by 17% (95% CI: -21% to -12%). This decrease was largely driven by reformulation (-12.0 mg/100 g). Changes in food choices reinforced the effects of the program, but had a smaller impact (-1.6 mg/100 g). These effects were similar across socioeconomic groups, whether stratified by education or income, with a consistent effect of reformulation across groups and no differences between groups in behavioral responses to the program.

CONCLUSIONS

A multi-component sodium reduction strategy deployed in the United Kingdom starting in 2003 corresponded to an important reduction in sodium intakes for the population. This reduction was mostly driven by changes in the food environment (reformulated food products to reduce the sodium density of foods) and, to a smaller extent, by changes in food choices. Impacts were consistent across socioeconomic groups.

What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Prevalence of chronic kidney disease in adults in England: comparison of nationally representative cross-sectional surveys from 2003 to 2016

OBJECTIVES

To identify recent trends in chronic kidney disease (CKD) prevalence in England and explore their association with changes in sociodemographic, behavioural and clinical factors.

DESIGN

Pooled cross-sectional analysis.

SETTING

Health Survey for England 2003, 2009/2010 combined and 2016.

PARTICIPANTS

17 663 individuals (aged 16+) living in private households.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and albuminuria (measured by albumin-creatinine ratio) during 2009/2010 and 2016 and trends in eGFR between 2003 and 2016. eGFR was estimated using serum creatinine Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease equations.

RESULTS

GFR <60 mL/min/1.73 m2 prevalence was 7.7% (95% CI 7.1% to 8.4%), 7.0% (6.4% to 7.7%) and 7.3%(6.5% to 8.2%) in 2003, 2009/2010 and 2016, respectively. Albuminuria prevalence was 8.7% (8.1% to 9.5%) in 2009/2010 and 9.8% (8.7% to 10.9%) in 2016. Prevalence of CKD G1-5 (eGFR <60 mL/min/1.73 m2 or albuminuria) was 12.6% (11.8% to 13.4%) in 2009/2010 and 13.9% (12.8% to 15.2%) in 2016. Prevalence of diabetes and obesity increased during 2003-2016 while prevalence of hypertension and smoking fell. The age-adjusted and gender-adjusted OR of eGFR <60 mL/min/1.73 m2 for 2016 versus 2009/2010 was 0.99 (0.82 to 1.18) and fully adjusted OR was 1.13 (0.93 to 1.37). There was no significant period effect on the prevalence of albuminuria or CKD G1-5 from 2009/2010 to 2016 in age and gender or fully adjusted models.

CONCLUSION

The fall in eGFR <60 mL/min/1.73 m2 seen from 2003 to 2009/2010 did not continue to 2016. However, absolute CKD burden is likely to rise with population growth and ageing, particularly if diabetes prevalence continues to increase. This highlights the need for greater CKD prevention efforts and continued surveillance.

Dietary Sodium Intake and Food Sources Among Chinese Adults: Data from the CNNHS 2010-2012

The present study was done to examine the status of dietary sodium intake and dietary sources of sodium among Chinese adults. Data were obtained from China National Nutrition and Health Surveillance (CNNHS) 2010–2012. All adults recruited in this study provided complete dietary data on three-day consecutive 24-h dietary recalls combining with the household weighing method. Sodium intake was adjusted for energy to 2000 kcal/day using the residual method. Average sodium intake was 5013 (95% Confidence Interval, CI: 4858, 5168) mg/day, and 92.6% of adults’ sodium intake exceeded the standard in the Chinese proposed intake for preventing non-communicable chronic diseases (PI-NCD). The salt added to food was the main contributor to daily sodium intake, representing 69.2% of the total sodium consumption. The proportion of sodium from salt was different in some subgroups. The contribution ranged from 64.8% for those who came from urban areas aged 18–49 years old to 74.7% for those who came from rural areas with education levels of primary school or less, and sodium from soy sauce was the next highest contributor (8.2%). The proportion of the subjects with sodium intake contributed by flour products was higher in the north with 7.1% than the south with 1.4%. The average consumption of sodium among Chinese was more than the recommended amount, and salt was the main source of sodium.

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 IMPACT_NCD 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.

Sodium and Potassium Intake, Knowledge Attitudes and Behaviour Towards Salt Consumption Amongst Adults in Podgorica, Montenegro

Excess salt and inadequate potassium intakes are associated with high cardiovascular disease (CVD). In Montenegro, CVD is the leading cause of death and disability. There is no survey that has directly measured salt and potassium consumption in Montenegro. The aim is to estimate population salt and potassium intakes and explore knowledge, attitudes and behaviour (KAB), amongst the adult population of Podgorica. Random samples of adults were obtained from primary care centres. Participants attended a screening including demographic, anthropometric and physical measurements. Dietary salt and potassium intakes were assessed by 24 h urinary sodium (UNa) and potassium (UK) excretions. Creatinine was measured. KAB was collected by questionnaire. Six hundred and thirty-nine (285 men, 25⁻65 years) were included in the analysis (response rate 63%). Mean UNa was 186.5 (SD 90.3) mmoL/day, equivalent to 11.6 g of salt/day and potassium excretion 62.5 (26.2) mmoL/day, equivalent to 3.2 g/day. Only 7% of them had a salt intake below the World Health Organization (WHO) recommended target of 5 g/day and 13% ate enough potassium (>90 mmoL/day). The majority (86%) knew that high salt causes ill-health. However, only 44% thought it would be useful to reduce consumption. Salt consumption is high and potassium consumption is low, in men and women living in Podgorica.

Trends of mortality attributable to child and maternal undernutrition, overweight/obesity and dietary risk factors of non-communicable diseases in sub-Saharan Africa, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To assess trends of mortality attributable to child and maternal undernutrition (CMU), overweight/obesity and dietary risks of non-communicable diseases (NCD) in sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD) Study 2015.

DESIGN

For each risk factor, a systematic review of data was used to compute the exposure level and the effect size. A Bayesian hierarchical meta-regression analysis was used to estimate the exposure level of the risk factors by age, sex, geography and year. The burden of all-cause mortality attributable to CMU, fourteen dietary risk factors (eight diets, five nutrients and fibre intake) and overweight/obesity was estimated.

SETTING

Sub-Saharan Africa.ParticipantsAll age groups and both sexes.

RESULTS

In 2015, CMU, overweight/obesity and dietary risks of NCD accounted for 826204 (95 % uncertainty interval (UI) 737346, 923789), 266768 (95 % UI 189051, 353096) and 558578 (95 % UI 453433, 680197) deaths, respectively, representing 10·3 % (95 % UI 9·1, 11·6 %), 3·3 % (95 % UI 2·4, 4·4 %) and 7·0 % (95 % UI 5·8, 8·3 %) of all-cause mortality. While the age-standardized proportion of all-cause mortality accounted for by CMU decreased by 55·2 % between 1990 and 2015 in SSA, it increased by 63·3 and 17·2 % for overweight/obesity and dietary risks of NCD, respectively.

CONCLUSIONS

The increasing burden of diet- and obesity-related diseases and the reduction of mortality attributable to CMU indicate that SSA is undergoing a rapid nutritional transition. To tackle the impact in SSA, interventions and international development agendas should also target dietary risks associated with NCD and overweight/obesity.

Validity of predictive equations for 24-h urinary potassium excretion based on timing of spot urine collection among adults: the MESA and CARDIA Urinary Sodium Study and NHANES Urinary Sodium Calibration Study

Background

24-h urine collections are the suggested method to measure daily urinary potassium excretion (uK) but are costly and burdensome to implement.

Objective

This study tested how well existing equations with the use of spot urine samples can estimate 24-h uK and if accuracy varies by timing of spot urine collection, age, race, or sex.

Design

This cross-sectional study used data from 407 participants aged 18-39 y from the Washington, DC area in 2011 and 554 participants aged 45-79 y from Chicago in 2013. Spot urine samples were collected in individual containers for 24 h, and 1 for each timed period (morning, afternoon, evening, and overnight) was selected. For each selected timed spot urine, 24-h uK was predicted through the use of published equations. Difference (bias) between predicted and measured 24-h uK was calculated for each timed period and within age, race, and sex subgroups. Individual-level differences were assessed through the use of Bland-Altman plots and correlation tests.

Results

For all equations, regardless of the timing of spot urine, mean bias was usually significantly different than 0. No one prediction equation was unbiased across all sex, race, and age subgroups. With the use of the Kawasaki and Tanaka equations, 24-h uK was overestimated at low levels and underestimated at high levels, whereas observed differential bias with the Mage equation was in the opposite direction. Depending on prediction equation and timing of urine sample, 61-75% of individual 24-h uKs were misclassified among 500-mg incremental categories from <1500 to ≥3000 mg. Correlations between predicted and measured 24-h uK were poor to moderate (0.19-0.71).

Conclusion

Because predicted 24-h uK accuracy varies by timing of spot urine collection, published prediction equations, and within age-race-sex subgroups, study results making use of predicted 24-h uK in association with health outcomes should be interpreted with caution. It is possible that a more accurate prediction equation can be developed leading to different results.

Making salt-reduced products more appealing to consumers: impact of front-of-pack messages on liking and table salt use over time

Objective

The current study investigated the impact of different front-of-pack messages on liking, salt perception and table salt use of salt-reduced soups over repeated consumption.

Design

In a between-subjects design, participants consumed a chicken noodle soup five times over 3 weeks. Participants were assigned to one of five experimental conditions and were categorized into three ‘Interest in Salt Reduction’ groups based on their self-reported interest in salt reduction. They consumed a regular-salt soup or a 30 % salt-reduced soup, either with or without a front-of-pack message (nutritional, sensory or social based). Liking, salt perception and table salt use were measured at each consumption.

Setting

Central location test.

Subjects

British consumers (n 493) aged 24–65 years.

Results

The soups remained stable in liking over repeated consumption, with no significant differences between the experimental conditions. However, liking did differ among the different Interest in Salt Reduction groups: the ‘not aware, no action’ group liked salt-reduced soups with a nutritional message the most, whereas the ‘aware and action’ group liked salt-reduced soups with a social message the most. There was no change in the amount of table salt added as people got more familiar with the salt-reduced soups, suggesting a strong role for habit in table salt use.

Conclusions

It mattered whether consumers were thinking about reducing their salt intake or not: a communication message tailored to a country’s interest in reducing salt is recommended to motivate consumers to lower their salt intake.

Population-level interventions in government jurisdictions for dietary sodium reduction: a Cochrane Review

Background

Worldwide, excessive salt consumption is common and is a leading cause of high blood pressure. Our objectives were to assess the overall and differential impact (by social and economic indicators) of population-level interventions for dietary sodium reduction in government jurisdictions worldwide.

Methods

This is a Cochrane systematic review. We searched nine peer-reviewed databases, seven grey literature resources and contacted national programme leaders. We appraised studies using an adapted version of the Cochrane risk of bias tool. To assess impact, we computed the mean change in salt intake (g/day) from before to after intervention.

Results

Fifteen initiatives met the inclusion criteria and 10 provided sufficient data for quantitative analysis of impact. Of these, five showed a mean decrease in salt intake from before to after intervention including: China, Finland (Kuopio area), France, Ireland and the UK. When the sample was constrained to the seven initiatives that were multicomponent and incorporated activities of a structural nature (e.g. procurement policy), most (4/7) showed a mean decrease in salt intake. A reduction in salt intake was more apparent among men than women. There was insufficient information to assess differential impact by other social and economic axes. Although many initiatives had methodological strengths, all scored as having a high risk of bias reflecting the observational design. Study heterogeneity was high, reflecting different contexts and initiative characteristics.

Conclusions

Population-level dietary sodium reduction initiatives have the potential to reduce dietary salt intake, especially if they are multicomponent and incorporate intervention activities of a structural nature. It is important to consider data infrastructure to permit monitoring of these initiatives.

The Validity of Predictive Equations to Estimate 24-Hour Sodium Excretion: The MESA and CARDIA Urinary Sodium Study

We examined the population distribution of urinary sodium concentrations and the validity of existing equations predicting 24-hour sodium excretion from a single spot urine sample among older adults with and without hypertension. In 2013, 24-hour urine collections were obtained from 554 participants in the Multi-Ethnic Study of Atherosclerosis and the Coronary Artery Risk Development in Young Adults study, who were aged 45-79 years and of whom 56% were female, 58% were African American, and 54% had hypertension, in Chicago, Illinois. One-third provided a second 24-hour collection. Four timed (overnight, morning, afternoon, and evening) spot urine specimens and the 24-hour collection were analyzed for sodium and creatinine concentrations. Mean 24-hour sodium excretion was 3,926 (standard deviation (SD), 1,623) mg for white men, 2,480 (SD, 1,079) mg for white women, 3,454 (SD, 1,651) mg for African-American men, and 3,397 (SD, 1,641) mg for African-American women, and did not differ significantly by hypertensive status. Mean bias (difference) in predicting 24-hour sodium excretion from the timed spot urine specimens ranged from -182 (95% confidence interval: -285, -79) to 1,090 (95% confidence interval: 966, 1,213) mg/day overall. Although the Tanaka equation using the evening specimen produced the least bias overall, no single equation worked well across subgroups of sex and race/ethnicity. A single spot urine sample is not a valid indicator of individual sodium intake. New equations are needed to accurately estimate 24-hour sodium excretion for older adults.

Ultra-processed foods and the limits of product reformulation

The nutritional reformulation of processed food and beverage products has been promoted as an important means of addressing the nutritional imbalances in contemporary dietary patterns. The focus of most reformulation policies is the reduction in quantities of nutrients-to-limit - Na, free sugars, SFA, trans-fatty acids and total energy. The present commentary examines the limitations of what we refer to as 'nutrients-to-limit reformulation' policies and practices, particularly when applied to ultra-processed foods and drink products. Beyond these nutrients-to-limit, there are a range of other potentially harmful processed and industrially produced ingredients used in the production of ultra-processed products that are not usually removed during reformulation. The sources of nutrients-to-limit in these products may be replaced with other highly processed ingredients and additives, rather than with whole or minimally processed foods. Reformulation policies may also legitimise current levels of consumption of ultra-processed products in high-income countries and increased levels of consumption in emerging markets in the global South.

Socioeconomic Determinants of Sodium Intake in Adult Populations of High-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND

A poorer quality diet among individuals with low socioeconomic status (SES) may partly explain the higher burden of noncommunicable disease among disadvantaged populations. Because there is a link between sodium intake and noncommunicable diseases, we systematically reviewed the current evidence on the social patterning of sodium intake.

OBJECTIVES

To conduct a systematic review and a meta-analysis of the evidence on the association between SES and sodium intake in healthy adult populations of high-income countries.

SEARCH METHODS

We followed the PRISMA-Equity guidelines in conducting a literature search that ended June 3, 2016, via MEDLINE, Embase, and SciELO. We imposed no publication date limits.

SELECTION CRITERIA

We considered only peer-reviewed articles meeting the following inclusion criteria: (1) reported a measure of sodium intake disaggregated by at least 1 measure of SES (education, income, occupation, or any other socioeconomic indicator); (2) were written in English, Spanish, Portuguese, French, or Italian; and (3) were conducted in a high-income country as defined by the World Bank (i.e., per capita national gross income was higher than $12 746). We also excluded articles that exclusively sampled low-SES individuals, pregnant women, children, adolescents, elderly participants, or diseased patients or that reported results from a trial or intervention.

DATA COLLECTION AND ANALYSIS

As summary measures, we extracted (1) the direction (positive, negative, or neutral) and the magnitude of the association between each SES indicator and sodium intake, and (2) the estimated sodium intake according to SES level. When possible and if previously unreported, we calculated the magnitude of the relative difference in sodium intake between high- and low-SES groups for each article, applying this formula: ([value for high-SES group - value for low-SES group]/[value for high-SES group]) × 100. We considered an association significant if reported as such, and we set an arbitrary 10% relative difference as clinically relevant and significant. We conducted a meta-analysis of the relative difference in sodium intake between high- and low-SES groups. We included articles in the meta-analysis if they reported urine-based sodium estimates and provided the total participant numbers in the low- and high-SES groups, the estimated sodium intake means for each group (in mg/day or convertible units), and the SDs (or transformable measures). We chose a random-effects model to account for both within-study and between-study variance.

MAIN RESULTS

Fifty-one articles covering 19 high-income countries met our inclusion criteria. Of these, 22 used urine-based methods to assess sodium intake, and 30 used dietary surveys. These articles assessed 171 associations between SES and sodium intake. Among urine-based estimates, 67% were negative (higher sodium intake in people of low SES), 3% positive, and 30% neutral. Among diet-based estimates, 41% were negative, 21% positive, and 38% neutral. The random-effects model indicated a 14% relative difference between low- and high-SES groups (95% confidence interval [CI] = -18, -9), corresponding to a global 503 milligrams per day (95% CI = 461, 545) of higher sodium intake among people of low SES.

CONCLUSIONS

People of low SES consume more sodium than do people of high SES, confirming the current evidence on socioeconomic disparities in diet, which may influence the disproportionate noncommunicable disease burden among disadvantaged socioeconomic groups. Public Health Implications. It is necessary to focus on disadvantaged populations to achieve an equitable reduction in sodium intake to a population mean of 2 grams per day as part of the World Health Organization's target to achieve a 25% relative reduction in noncommunicable disease mortality by 2025.

Review of behaviour change interventions to reduce population salt intake

Background

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

MAIN MEASURE

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

RESULTS

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

CONCLUSIONS

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

The Use and Interpretation of Sodium Concentrations in Casual (Spot) Urine Collections for Population Surveillance and Partitioning of Dietary Iodine Intake Sources

In 2013, the World Health Organization (WHO) called for joint surveillance of population salt and iodine intakes using urinary analysis. 24-h urine collection is considered the gold standard for salt intake assessment, but there is an emerging consensus that casual urine sampling can provide comparable information for population-level surveillance. Our review covers the use of the urinary sodium concentration (UNaC) and the urinary iodine concentration (UIC) from casual urine samples to estimate salt intakes and to partition the sources of iodine intakes. We reviewed literature on 24-h urinary sodium excretion (UNaE) and UNaC and documented the use of UNaC for national salt intake monitoring. We combined information from our review of urinary sodium with evidence on urinary iodine to assess the appropriateness of partitioning methods currently being adapted for cross-sectional survey analyses. At least nine countries are using casual urine collection for surveillance of population salt intakes; all these countries used single samples. Time trend analyses indicate that single UNaC can be used for monitoring changes in mean salt intakes. However; single UNaC suffers the same limitation as single UNaE; i.e., an estimate of the proportion excess salt intake can be biased due to high individual variability. There is evidence, albeit limited, that repeat UNaC sampling has good agreement at the population level with repeat UNaE collections; thus permitting an unbiased estimate of the proportion of excess salt intake. High variability of UIC and UNaC in single urine samples may also bias the estimates of dietary iodine intake sources. Our review concludes that repeated collection, in a sub-sample of individuals, of casual UNaC data would provide an immediate practical approach for routine monitoring of salt intake, because it overcomes the bias in estimates of excess salt intake. Thus we recommend more survey research to expand the evidence-base on predicted-UNaE from repeat casual UNaC sampling. We also conclude that the methodology for partitioning the sources of iodine intake based on the combination of UIC and UNaC measurements in casual urine samples can be improved by repeat collections of casual data; which helps to reduce regression dilution bias. We recommend more survey research to determine the effect of regression dilution bias and circadian rhythms on the partitioning of dietary iodine intake sources.

The impact of dietary risk factors on the burden of non-communicable diseases in Ethiopia: findings from the Global Burden of Disease study 2013

BACKGROUND

The burden of non-communicable diseases (NCDs) has increased in sub-Saharan countries, including Ethiopia. The contribution of dietary behaviours to the NCD burden in Ethiopia has not been evaluated. This study, therefore, aimed to assess diet-related burden of disease in Ethiopia between 1990 and 2013.

METHOD

We used the 2013 Global Burden of Disease (GBD) data to estimate deaths, years of life lost (YLLs) and disability-adjusted life years (DALYs) related to eight food types, five nutrients and fibre intake. Dietary exposure was estimated using a Bayesian hierarchical meta-regression. The effect size of each diet-disease pair was obtained based on meta-analyses of prospective observational studies and randomized controlled trials. A comparative risk assessment approach was used to quantify the proportion of NCD burden associated with dietary risk factors.

RESULTS

In 2013, dietary factors were responsible for 60,402 deaths (95% Uncertainty Interval [UI]: 44,943-74,898) in Ethiopia-almost a quarter (23.0%) of all NCD deaths. Nearly nine in every ten diet-related deaths (88.0%) were from cardiovascular diseases (CVD) and 44.0% of all CVD deaths were related to poor diet. Suboptimal diet accounted for 1,353,407 DALYs (95% UI: 1,010,433-1,672,828) and 1,291,703 YLLs (95% UI: 961,915-1,599,985). Low intake of fruits and vegetables and high intake of sodium were the most important dietary factors. The proportion of NCD deaths associated with low fruit consumption slightly increased (11.3% in 1990 and 11.9% in 2013). In these years, the rate of burden of disease related to poor diet slightly decreased; however, their contribution to NCDs remained stable.

CONCLUSIONS

Dietary behaviour contributes significantly to the NCD burden in Ethiopia. Intakes of diet low in fruits and vegetables and high in sodium are the leading dietary risks. To effectively mitigate the oncoming NCD burden in Ethiopia, multisectoral interventions are required; and nutrition policies and dietary guidelines should be developed.

An evidence-based conceptual framework of healthy cooking

Eating out of the home has been positively associated with body weight, obesity, and poor diet quality. While cooking at home has declined steadily over the last several decades, the benefits of home cooking have gained attention in recent years and many healthy cooking projects have emerged around the United States. The purpose of this study was to develop an evidence-based conceptual framework of healthy cooking behavior in relation to chronic disease prevention. A systematic review of the literature was undertaken using broad search terms. Studies analyzing the impact of cooking behaviors across a range of disciplines were included. Experts in the field reviewed the resulting constructs in a small focus group. The model was developed from the extant literature on the subject with 59 studies informing 5 individual constructs (frequency, techniques and methods, minimal usage, flavoring, and ingredient additions/replacements), further defined by a series of individual behaviors. Face validity of these constructs was supported by the focus group. A validated conceptual model is a significant step toward better understanding the relationship between cooking, disease and disease prevention and may serve as a base for future assessment tools and curricula.

Population-level interventions in government jurisdictions for dietary sodium reduction

BACKGROUND

Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population-level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives.

OBJECTIVES

• To assess the impact of population-level interventions for dietary sodium reduction in government jurisdictions worldwide.• To assess the differential impact of those initiatives by social and economic indicators.

SEARCH METHODS

We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non-Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies.This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide (Trieu 2015), through which we gained additional information directly from country contacts.We imposed no restrictions on language or publication status.

SELECTION CRITERIA

We included population-level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre-intervention data point and at least one post-intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster-randomised, controlled pre-post, interrupted time series and uncontrolled pre-post. We contacted study authors at different points in the review to ask for missing information.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data, and two review authors assessed risk of bias for each included initiative.We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre-intervention to post-intervention.

MAIN RESULTS

We reviewed a total of 881 full-text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower-middle-income or low-income countries. All initiatives except one used an uncontrolled pre-post study design.Because of high levels of study heterogeneity (I² > 90%), we focused on individual initiatives rather than on pooled results.Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre-intervention to post-intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre-intervention to post-intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person. The remaining initiatives did not show a statistically significant mean change.Seven of the 10 initiatives were multi-component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre-intervention to post-intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention (Switzerland; see above).Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention.Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre-intervention to post-intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence).We identified no adverse effects of these initiatives.The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative.Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact.

AUTHORS' CONCLUSIONS

Population-level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population-wide reductions in salt intake from pre-intervention to post-intervention, particularly if they are multi-component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects.

Trends and determinants of discretionary salt use: National Health and Nutrition Examination Survey 2003-2012

OBJECTIVE

To examine temporal trends and determinants of discretionary salt use in the USA.

DESIGN

Multiple logistic regression was used to assess temporal trends in discretionary salt use at the table and during home cooking/preparation, adjusting for demographic characteristics, using data from the National Health and Nutrition Examination Survey 2003-2012. Prevalence and determinants of discretionary salt use in 2009-2012 were also examined.

SETTING

Participants answered salt use questions after completing a 24 h dietary recall in a mobile examination centre.

SUBJECTS

Nationally representative sample of non-institutionalized US children and adults, aged ≥2 years.

RESULTS

From 2003 to 2012, the proportion of the population who reported using salt 'very often' declined; from 18 % to 12 % for use at the table (P<0·01) and from 42 % to 37 % during home cooking (P<0·02). While one-third of the population reported never adding salt at the table, most used it during home cooking/preparation (93 %). Use of discretionary salt was least commonly reported among young children and older adults and demographic and health subgroups at risk of CVD.

CONCLUSIONS

While most people reported using salt during home cooking/preparation, a minority reported use at the table. Reported 'very often' discretionary salt use has declined. That discretionary salt use is less common among those at risk of CVD suggests awareness of messages to limit Na intake.

Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis

BACKGROUND

People of Sub Saharan Africa (SSA) and South Asians(SA) ethnic minorities living in Europe have higher risk of stroke than native Europeans(EU). Study objective is to provide an assessment of gender specific absolute differences in office systolic(SBP) and diastolic(DBP) blood pressure(BP) levels between SSA, SA, and EU.

METHODS AND FINDINGS

We performed a systematic review and meta-analysis of observational studies conducted in Europe that examined BP in non-selected adult SSA, SA and EU subjects. Medline, PubMed, Embase, Web of Science, and Scopus were searched from their inception through January 31st 2015, for relevant articles. Outcome measures were mean SBP and DBP differences between minorities and EU, using a random effects model and tested for heterogeneity. Twenty-one studies involving 9,070 SSA, 18,421 SA, and 130,380 EU were included. Compared with EU, SSA had higher values of both SBP (3.38 mmHg, 95% CI 1.28 to 5.48 mmHg; and 6.00 mmHg, 95% CI 2.22 to 9.78 in men and women respectively) and DBP (3.29 mmHg, 95% CI 1.80 to 4.78; 5.35 mmHg, 95% CI 3.04 to 7.66). SA had lower SBP than EU(-4.57 mmHg, 95% CI -6.20 to -2.93; -2.97 mmHg, 95% CI -5.45 to -0.49) but similar DBP values. Meta-analysis by subgroup showed that SA originating from countries where Islam is the main religion had lower SBP and DBP values than EU. In multivariate meta-regression analyses, SBP difference between minorities and EU populations, was influenced by panethnicity and diabetes prevalence.

CONCLUSIONS

1) The higher BP in SSA is maintained over decades, suggesting limited efficacy of prevention strategies in such group in Europe;2) The lower BP in Muslim populations suggests that yet untapped lifestyle and behavioral habits may reveal advantages towards the development of hypertension;3) The additive effect of diabetes, emphasizes the need of new strategies for the control of hypertension in groups at high prevalence of diabetes.

The U.S. prevention of cardiovascular disease guidelines and implications for implementation in LMIC

The 2013 guidelines for the Prevention of Cardiovascular Disease released by the American College of Cardiology and the American Heart Association included guidelines of assessment of cardiovascular disease (CVD) risk, lifestyle management, management of overweight and obesity, and treatment of blood cholesterol. In addition, there were also 2014 guidelines on hypertension management released by members appointed to the Eighth Joint National Committee. Taken together, these guidelines, though extensively discussed and disseminated in the United States, have not been widely recognized beyond the United States, nor have their implications been considered for lower- and middle-income developing countries. With an estimated 80% of the global burden in CVD occurring in developing countries, it is important to develop strategies to adequately detect those at increased CVD risk and to manage their risk through lifestyle and where appropriate, pharmacologic means. Though certain aspects of each guideline may be suitable for implementation globally, including in developing countries, other recommendations would be unrealistic for many countries based on local epidemiology and resources. CVD prevention priorities can be set using guidance from recently published CVD prevention guidelines if appropriately modified to the context of lower- and middle-income developing countries. Establishment of global CVD prevention standards and rapid adaptation and dissemination of clinical guidelines are of paramount importance if we are to make significant progress into achieving World Health Organization 2025 goals to reduce the burden from CVD and other noncommunicable diseases.

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

BACKGROUND

Public health action to reduce dietary salt intake has driven substantial reductions in coronary heart disease (CHD) over the past decade, but avoidable socio-economic differentials remain. We therefore forecast how further intervention to reduce dietary salt intake might affect the overall level and inequality of CHD mortality.

METHODS

We considered English adults, with socio-economic circumstances (SEC) stratified by quintiles of the Index of Multiple Deprivation. We used IMPACTSEC, a validated CHD policy model, to link policy implementation to salt intake, systolic blood pressure and CHD mortality. We forecast the effects of mandatory and voluntary product reformulation, nutrition labelling and social marketing (e.g., health promotion, education). To inform our forecasts, we elicited experts' predictions on further policy implementation up to 2020. We then modelled the effects on CHD mortality up to 2025 and simultaneously assessed the socio-economic differentials of effect.

RESULTS

Mandatory reformulation might prevent or postpone 4,500 (2,900-6,100) CHD deaths in total, with the effect greater by 500 (300-700) deaths or 85% in the most deprived than in the most affluent. Further voluntary reformulation was predicted to be less effective and inequality-reducing, preventing or postponing 1,500 (200-5,000) CHD deaths in total, with the effect greater by 100 (-100-600) deaths or 49% in the most deprived than in the most affluent. Further social marketing and improvements to labelling might each prevent or postpone 400-500 CHD deaths, but minimally affect inequality.

CONCLUSIONS

Mandatory engagement with industry to limit salt in processed-foods appears a promising and inequality-reducing option. For other policy options, our expert-driven forecast warns that future policy implementation might reach more deprived individuals less well, limiting inequality reduction. We therefore encourage planners to prioritise equity.

Use of Urine Biomarkers to Assess Sodium Intake: Challenges and Opportunities

This article summarizes current data and approaches to assess sodium intake in individuals and populations. A review of the literature on sodium excretion and intake estimation supports the continued use of 24-h urine collections for assessing population and individual sodium intake. Since 2000, 29 studies used urine biomarkers to estimate population sodium intake, primarily among adults. More than half used 24-h urine; the rest used a spot/casual, overnight, or 12-h specimen. Associations between individual sodium intake and health outcomes were investigated in 13 prospective cohort studies published since 2000. Only three included an indicator of long-term individual sodium intake, i.e., multiple 24-h urine specimens collected several days apart. Although not insurmountable, logistic challenges of 24-h urine collection remain a barrier for research on the relationship of sodium intake and chronic disease. Newer approaches, including modeling based on shorter collections, offer promise for estimating population sodium intake in some groups.

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact

BACKGROUND

Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP).

METHODS

We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person".

RESULTS

Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities.

CONCLUSIONS

Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.

Reduced dietary salt for the prevention of cardiovascular disease

BACKGROUND

This is an update of a Cochrane review that was first published in 2011 of the effects of reducing dietary salt intake, through advice to reduce salt intake or low-sodium salt substitution, on mortality and cardiovascular events.

OBJECTIVES

1. To assess the long-term effects of advice and salt substitution, aimed at reducing dietary salt, on mortality and cardiovascular morbidity.2. To investigate whether a reduction in blood pressure is an explanatory factor in the effect of such dietary interventions on mortality and cardiovascular outcomes.

SEARCH METHODS

We updated the searches of CENTRAL (2013, Issue 4), MEDLINE (OVID, 1946 to April week 3 2013), EMBASE (OVID, 1947 to 30 April 2013) and CINAHL (EBSCO, inception to 1 April 2013) and last ran these on 1 May 2013. We also checked the references of included studies and reviews. We applied no language restrictions.

SELECTION CRITERIA

Trials fulfilled the following criteria: (1) randomised, with follow-up of at least six months, (2) the intervention was reduced dietary salt (through advice to reduce salt intake or low-sodium salt substitution), (3) participants were adults and (4) mortality or cardiovascular morbidity data were available. Two review authors independently assessed whether studies met these criteria.

DATA COLLECTION AND ANALYSIS

A single author extracted data and assessed study validity, and a second author checked this. We contacted trial authors where possible to obtain missing information. We extracted events and calculated risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

Eight studies met the inclusion criteria: three in normotensives (n = 3518) and five in hypertensives or mixed populations of normo- and hypertensives (n = 3766). End of trial follow-up ranged from six to 36 months and the longest observational follow-up (after trial end) was 12.7 years.The risk ratios (RR) for all-cause mortality in normotensives were imprecise and showed no evidence of reduction (end of trial RR 0.67, 95% confidence interval (CI) 0.40 to 1.12, 60 deaths; longest follow-up RR 0.90, 95% CI 0.58 to 1.40, 79 deaths n=3518) or in hypertensives (end of trial RR 1.00, 95% CI 0.86 to 1.15, 565 deaths; longest follow-up RR 0.99, 95% CI 0.87 to 1.14, 674 deaths n=3085). There was weak evidence of benefit for cardiovascular mortality (hypertensives: end of trial RR 0.67, 95% CI 0.45 to 1.01, 106 events n=2656) and for cardiovascular events (hypertensives: end of trial RR 0.76, 95% CI 0.57 to 1.01, 194 events, four studies, n = 3397; normotensives: at longest follow-up RR 0.71, 95% CI 0.42 to 1.20, 200 events; hypertensives: RR 0.77, 95% CI 0.57 to 1.02, 192 events; pooled analysis of six trials RR 0.77, 95% CI 0.63 to 0.95, n = 5912). These findings were driven by one trial among retirement home residents that reduced salt intake in the kitchens of the homes, thereby not requiring individual behaviour change.Advice to reduce salt showed small reductions in systolic blood pressure (mean difference (MD) -1.15 mmHg, 95% CI -2.32 to 0.02 n=2079) and diastolic blood pressure (MD -0.80 mmHg, 95% CI -1.37 to -0.23 n=2079) in normotensives and greater reductions in systolic blood pressure in hypertensives (MD -4.14 mmHg, 95% CI -5.84 to -2.43 n=675), but no difference in diastolic blood pressure (MD -3.74 mmHg, 95% CI -8.41 to 0.93 n=675).Overall many of the trials failed to report sufficient detail to assess their potential risk of bias. Health-related quality of life was assessed in one trial in normotensives, which reported significant improvements in well-being but no data were presented.

AUTHORS' CONCLUSIONS

Despite collating more event data than previous systematic reviews of randomised controlled trials, there is insufficient power to confirm clinically important effects of dietary advice and salt substitution on cardiovascular mortality in normotensive or hypertensive populations. Our estimates of the clinical benefits from advice to reduce dietary salt are imprecise, but are larger than would be predicted from the small blood pressure reductions achieved. Further well-powered studies would be needed to obtain more precise estimates. Our findings do not support individual dietary advice as a means of restricting salt intake. It is possible that alternative strategies that do not require individual behaviour change may be effective and merit further trials.

Change in prevalence of chronic kidney disease in England over time: comparison of nationally representative cross-sectional surveys from 2003 to 2010

OBJECTIVES

To determine whether the prevalence of chronic kidney disease (CKD) in England has changed over time.

DESIGN

Cross-sectional analysis of nationally representative Health Survey for England (HSE) random samples.

SETTING

England 2003 and 2009/2010.

SURVEY PARTICIPANTS

13,896 adults aged 16+ participating in HSE, adjusted for sampling and non-response, 2009/2010 surveys combined.

MAIN OUTCOME MEASURE

Change in prevalence of estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2 (as proxy for stage 3-5 CKD), from 2003 to 2009/2010 based on a single serum creatinine measure using an isotope dilution mass spectrometry traceable enzymatic assay in a single laboratory; eGFR derived using Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) eGFR formulae.

ANALYSIS

Multivariate logistic regression modelling to adjust time changes for sociodemographic and clinical factors (body mass index, hypertension, diabetes, lipids). A correction factor was applied to the 2003 HSE serum creatinine to account for a storage effect.

RESULTS

National prevalence of low eGFR (<60) decreased within each age and gender group for both formulae except in men aged 65-74. Prevalence of obesity and diabetes increased in this period, while there was a decrease in hypertension. Adjustment for demographic and clinical factors led to a significant decrease in CKD between the surveyed periods. The fully adjusted OR for eGFR<60 mL/min/1.73 m2 was 0.75 (0.61 to 0.92) comparing 2009/2010 with 2003 using the MDRD equation, and was similar using the CKDEPI equation 0.73 (0.57 to 0.93).

CONCLUSIONS

The prevalence of a low eGFR indicative of CKD in England appeared to decrease over this 7-year period, despite the rising prevalence of obesity and diabetes, two key causes of CKD. Hypertension prevalence declined and blood pressure control improved but this did not appear to explain the fall. Periodic assessment of eGFR and albuminuria in future HSEs is needed to evaluate trends in CKD.

A repeated cross-sectional study of socio-economic inequities in dietary sodium consumption among Canadian adults: implications for national sodium reduction strategies

INTRODUCTION

In many countries including Canada, excess consumption of dietary sodium is common, and this has adverse implications for population health. Socio-economic inequities in sodium consumption seem likely, but research is limited. Knowledge of socio-economic inequities in sodium consumption is important for informing population-level sodium reduction strategies, to ensure that they are both impactful and equitable.

METHODS

We examined the association between socio-economic indicators (income and education) and sodium, using two outcome variables: 1) sodium consumption in mg/day, and 2) reported use of table salt, in two national surveys: the 1970/72 Nutrition Canada Survey and the 2004 Canadian Community Health Survey, Cycle 2.2. This permitted us to explore whether there were any changes in socio-economic patterning in dietary sodium during a time period characterized by modest, information-based national sodium reduction efforts, as well as to provide baseline information against which to examine the impact (equitable or not) of future sodium reduction strategies in Canada.

RESULTS

There was no evidence of a socio-economic inequity in sodium consumption (mg/day) in 2004. In fact findings pointed to a positive association in women, whereby women of higher education consumed more sodium than women of lower education in 2004. For men, income was positively associated with reported use of table salt in 1970/72, but negatively associated in 2004.

CONCLUSIONS

An emerging inequity in reported use of table salt among men could reflect the modest, information-based sodium reduction efforts that were implemented during the time frame considered. However, for sodium consumption in mg/day, we found no evidence of a contemporary inequity, and in fact observed the opposite effect among women. Our findings could reflect data limitations, or they could signal that sodium differs from some other nutrients in terms of its socio-economic patterning, perhaps reflecting very high prevalence of excess consumption. It is possible that socio-economic inequities in sodium consumption will emerge as excess consumption declines, consistent with fundamental cause theory. It is important that national sodium reduction strategies are both impactful and equitable.

Demographic associations of high estimated sodium intake and frequency of consumption of high-sodium foods in people with chronic kidney disease stage 3 in England

OBJECTIVE

The objective of this study was to investigate sodium intake in a cohort of people with chronic kidney disease (CKD) Stage 3 in England to identify demographic characteristics of subgroups with high sodium intake and specific foods that contribute to excessive sodium intake.

DESIGN AND METHODS

Study subjects (N = 1,729) included CKD patients from 32 general practices in the Renal Risk in Derby study. Patients had a glomerular filtration rate between 30 and 59 mL/min per 1.73 m(2) on 2 or more occasions at least 3 months apart before recruitment. Sodium excretion (assumed to be equal to intake) was estimated from early morning urine specimens using an equation validated for this study population. The frequency of intake of 12 salty foods was assessed by a food frequency questionnaire.

RESULTS

The mean estimated urinary sodium excretion was 110.5 ± 33.8 mmol/day; 60.1% had values above the National Kidney Foundation recommendation (<100 mmol/day). Subgroups with a greater percentage of participants having sodium excretion above the recommendation were as follows: men, those younger than 75 years of age, those with central obesity or diabetes, those with formal educational qualifications, and those who were previous or current smokers. In multivariable analysis, gender, younger age, waist-to-hip ratio, and diabetes mellitus status were the main independent determinants of excessive sodium excretion. Specific food items that contributed to excessive intake were table and cooking salt, salted snacks, hard cheeses, processed meat, and tinned fish. The most important source of sodium varied by subgroup.

CONCLUSION

A high prevalence of sodium excretion above the recommended value was detected, and independent determinants were gender, age, waist-to-hip ratio, and diabetes mellitus. Specific food items that contributed to excessive intake were also identified and varied in different subgroups. These data will be helpful in informing strategies to target dietetic advice to those most likely to have high sodium intake and will allow dietitians to focus on the most likely sources of sodium in different subgroups.

Healthy food procurement policies and their impact

Unhealthy eating is the leading risk for death and disability globally. As a result, the World Health Organization (WHO) has called for population health interventions. One of the proposed interventions is to ensure healthy foods are available by implementing healthy food procurement policies. The objective of this systematic review was to evaluate the evidence base assessing the impact of such policies. A comprehensive review was conducted by searching PubMed and Medline for policies that had been implemented and evaluated the impact of food purchases, food consumption, and behaviors towards healthy foods. Thirty-four studies were identified and found to be effective at increasing the availability and purchases of healthy food and decreasing purchases of unhealthy food. Most policies also had other components such as education, price reductions, and health interventions. The multiple gaps in research identified by this review suggest that additional research and ongoing evaluation of food procurement programs is required. Implementation of healthy food procurement policies in schools, worksites, hospitals, care homes, correctional facilities, government institutions, and remote communities increase markers of healthy eating. Prior or simultaneous implementation of ancillary education about healthy eating, and rationale for the policy may be critical success factors and additional research is needed.

The population risks of dietary salt excess are exaggerated

Policy positions on salt consumption (based largely on the association of sodium and blood pressure [BP]) has remained unchanged since the 1970s, until recently. However, this is beginning to change as new evidence emerges. The evidence supports a strong association of sodium with BP and cardiovascular disease events in hypertensive individuals, the elderly, and those who consume > 6 g/d of sodium. However, there is no association of sodium with clinical events at 3 to 6 g/day and a paradoxical higher rate of events at < 3 g/day. Therefore, until new evidence emerges, the optimal range of sodium consumption should be considered to be between 3 and 6 g/d. Population-wide sodium reduction is not justified in countries such as Canada.