Potential effect of salt reduction in processed foods on health

A holistic review of sodium intake in kidney transplant patients: More questions than answers

Kidney transplantation (KT) is the best treatment option for end-stage kidney disease (ESKD). Acute rejection rates have decreased drastically in recent years but chronic kidney allograft disease (CKAD) is still an important cause of allograft failure and return to dialysis. Thus, there is unmet need to identify and reverse the cause of CKAD. Additionally, cardiovascular events after KT are still leading causes of morbidity and mortality. One overlooked potential contributor to CKAD and adverse cardiovascular events is increased sodium/salt intake in kidney transplant recipients (KTRs). In general population, the adverse effects of high sodium intake are well known but in KTRs, there is a paucity of evidence despite decades of experience with KT. Limited research showed that sodium intake is high in most KTRs. Moreover, excess sodium intake is associated with elevated blood pressure and albuminuria in some studies involving KTRs. There is also experimental evidence suggesting that increased sodium intake is associated with histologic graft damage. Critical knowledge gaps still remain, including the exact amount of sodium restriction needed in KTRs to optimize outcomes and allograft survival. Additionally, best methods to measure sodium intake and practices to follow-up are not clarified in KTRs. To meet these deficits, prospective long term studies are warranted in KTRs. Moreover, preventive measures must be determined and implemented both at individual and societal levels to achieve sodium restriction in KTRs.

Corneal densitometry in Chinese adults with healthy corneas: associations with sex, age, ocular metrics, and optical characteristics

BACKGROUND

Standardized corneal densitometry (CD) values in large samples of healthy Chinese individuals are scarce. Therefore, we aimed to determine the standard CD values using a Scheimpflug camera in healthy corneas, investigate the correlations of sex, age, and ocular parameters with corneal density, and explore the impact of corneal density on the forward scattering and optical quality of the eye.

METHODS

This retrospective observational study involved 990 healthy Chinese individuals, including 494 males and 496 females (mean age: 23.88 ± 6.90 years). The CD values at various depths and radial areas of 0-12 mm were measured using a Scheimpflug camera. Densitometric measurements were expressed in standardized grayscale units (GSU). The optical scatter index (OSI), modulation transfer function cutoff values (MTFcutoff), and Strehl's ratio (SR) were also determined using an optical quality analysis system.

RESULTS

The average CD within a 12 mm diameter area was 16.26 ± 1.35 GSU. The highest and lowest optical densities at different depths were observed in the anterior (21.41 ± 2.16 GSU) and posterior (12.00 ± 1.01 GSU) layers, respectively (P < 0.001). Similarly, the maximum and minimum optical densities at different radial areas were observed in the 10-12 mm (14.09 ± 0.93 GSU) and 2-6 mm (25.93 ± 4.77 GSU) circles, respectively (P < 0.001). There was no significant difference in the average CD within a 12 mm diameter area between males and females (P > 0.05). However, upon adjusting for age, central corneal thickness (CCT), corneal curvature, white-to-white (WTW) corneal diameter, and axial length, females exhibited a greater average CD within the 12 mm diameter and in the 6-10 mm and 10-12 mm circles than males. Age-related changes in CD were evident, except in the 2-6 mm circle. CCT, corneal curvature, WTW corneal diameter, and partial depth correlated with CD in the radial area, and CD in different areas correlated with the OSI, MTFcutoff, and SR (P < 0.05).

CONCLUSIONS

This study provides the normative CD measurement data of Chinese adults with healthy corneas, emphasizing the significance of sex, age, CCT, corneal curvature, and WTW corneal diameter in CD evaluation. Notably, elevated CD can lead to increased forward scattering within the eye, thereby affecting the optical quality.

Estimated Dietary and Health Impact of the World Health Organization's Global Sodium Benchmarks on Packaged Foods in Australia: a Modeling Study

BACKGROUND

In 2021, the World Health Organization (WHO) set sodium benchmarks for packaged foods to guide countries in setting feasible and effective sodium reformulation programs. We modeled the dietary and health impact of full compliance with the WHO's sodium benchmarks in Australia and compared it to the potential impact of Australia's 2020 sodium reformulation targets.

METHODS

We used nationally representative data on food and sodium intake, sodium levels in packaged foods, and food sales volume to estimate sodium intake pre- and post-implementation of the WHO and Australia's sodium benchmarks for 24 age-sex groups. Using comparative risk assessment models, we then estimated the potential deaths, incidence, and disability-adjusted life years averted from cardiovascular disease, chronic kidney disease, and stomach cancer based on the reductions in sodium intake.

RESULTS

Compliance with the WHO's sodium benchmarks for packaged foods in Australia could lower mean adult sodium intake by 404 mg/day, corresponding to a 12% reduction. This could prevent about 1770 deaths/year (95% uncertainty interval 1168-2587), corresponding to 3% of all cardiovascular disease, chronic kidney disease, and stomach cancer deaths in Australia, and prevent some 6900 (4603-9513) new cases, and 25 700 (17 655-35 796) disability-adjusted life years/year. Compared with Australian targets, the WHO benchmarks will avert around 3 and a half times more deaths each year (1770 versus 510).

CONCLUSIONS

Substantially greater health impact could be achieved if the Australian government strengthened its current sodium reformulation program by adopting WHO's more stringent and comprehensive sodium benchmarks.

High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

The estimated health impact of sodium reduction through food reformulation in Australia: A modeling study

BACKGROUND

The Australian Government recently established sodium targets for packaged foods to encourage voluntary reformulation to reduce population sodium consumption and related diseases. We modeled the health impact of Australia's sodium reformulation targets and additional likely health gains if more ambitious, yet feasible sodium targets had been adopted instead.

METHODS AND FINDINGS

Using comparative risk assessment models, we estimated the averted deaths, incidence, and disability-adjusted life years (DALYs) from cardiovascular disease (CVD), chronic kidney disease (CKD) and stomach cancer after implementation of (a) Australia's sodium targets (overall and by individual companies); (b) United Kingdom's targets (that covers more product categories); and (c) an optimistic scenario (sales-weighted 25th percentile sodium content for each food category included in the UK program). We used nationally representative data to estimate pre- and post-intervention sodium intake, and other key data sources from the Global Burden of Disease study. Full compliance with the Australian government's sodium targets could prevent approximately 510 deaths/year (95% UI, 335 to 757), corresponding to about 1% of CVD, CKD, and stomach cancer deaths, and prevent some 1,920 (1,274 to 2,600) new cases and 7,240 (5,138 to 10,008) DALYs/year attributable to these diseases. Over half (59%) of deaths prevented is attributed to reformulation by 5 market-dominant companies. Compliance with the UK and optimistic scenario could avert approximately an additional 660 (207 to 1,227) and 1,070 (511 to 1,856) deaths/year, respectively, compared to Australia's targets. The main limitation of this study (like other modeling studies) is that it does not prove that sodium reformulation programs will prevent deaths and disease events; rather, it provides the best quantitative estimates and the corresponding uncertainty of the potential effect of the different programs to guide the design of policies.

CONCLUSIONS

There is significant potential to strengthen Australia's sodium reformulation targets to improve its health impact. Promoting compliance by market-dominant food companies will be critical to achieving the potential health gains.

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

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

Food Literacy Is Associated With Adherence to a Mediterranean-Style Diet in Kidney Transplant Recipients

OBJECTIVES

Adherence to a Mediterranean-style diet is associated with improved health outcomes in kidney transplant recipients (KTR). However, poor dietary habits, including excessive sodium intake, are common in KTR, indicating difficulties with incorporating a healthy diet into daily life. Food literacy is identified as potential facilitator of a healthy diet, but the precise relationship between food literacy and dietary intake in KTR has not been investigated. This study examined food literacy levels in KTR and its association with adherence to a Mediterranean-style diet and sodium intake.

METHODS

This cross-sectional study is part of the TransplantLines Cohort and Biobank Study. Food literacy was measured with the Self-Perceived Food Literacy (SPFL) questionnaire. Dietary intake assessment with food frequency questionnaires was used to calculate the Mediterranean Diet Score. Sodium intake was based on the 24-hour urinary sodium excretion rate. Associations of SPFL with Mediterranean Diet Score and sodium intake were assessed with univariable and multivariable linear regression analyses.

RESULTS

In total, 148 KTR (age 56 [48-66]; 56% male) completed the SPFL questionnaire with a mean SPFL score of 3.63 ± 0.44. Higher SPFL was associated with a higher Mediterranean Diet Score in KTR (β = 1.51, 95% confidence interval 0.88-2.12, P ≤ .001). Although KTR with higher food literacy tended to have a lower sodium intake than those with lower food literacy (P = .08), the association of food literacy with sodium intake was not significant in a multivariable regression analysis (β = 0.52 per 10 mmol/24-hour increment, 95% confidence interval -1.79 to 2.83, P = .66).

CONCLUSIONS

Higher levels of food literacy are associated with better adherence to a Mediterranean-style diet in KTR. No association between food literacy and sodium intake was found. Further studies are needed to determine if interventions on improving food literacy contribute to a healthier diet and better long-term outcomes in KTR.

Zoonotic evolution and implications of microbiome in viral transmission and infection

The outbreak and spread of new strains of coronavirus (SARS-CoV-2) remain a global threat with increasing cases in affected countries. The evolutionary tree of SARS-CoV-2 revealed that Porcine Reproductive and Respiratory Syndrome virus 2, which belongs to the Beta arterivirus genus from the Arteriviridae family is possibly the most ancient ancestral origin of SARS-CoV-2 and other Coronaviridae. This review focuses on phylogenomic distribution and evolutionary lineage of zoonotic viral cross-species transmission of the Coronaviridae family and the implications of bat microbiome in zoonotic viral transmission and infection. The review also casts light on the role of the human microbiome in predicting and controlling viral infections. The significance of microbiome-mediated interventions in the treatment of viral infections is also discussed. Finally, the importance of synthetic viruses in the study of viral evolution and transmission is highlighted.

Obesity as a risk factor for COVID-19: an overview

The current coronavirus disease-2019 (COVID-19) pandemic presents a huge challenge for health-care systems worldwide. Many different risk factors are associated with disease severity, such as older age, diabetes, hypertension, and most recently obesity. The incidence of obesity has been on the rise for the past 25 years, reaching over 2 billion people throughout the world, and obesity itself could be considered a pandemic. In this review, we summarize aspects involved with obesity, such as changes in the immune response, nutritional factors, physiological factors, and the gut-lung axis, that impact the viral response and the COVID-19 prognosis.

An Evaluation of the Sodium Content and Compliance with the National Sodium Reduction Targets among Packaged Foods Sold in Costa Rica in 2015 and 2018

High blood pressure is a leading cause of death in Costa Rica, with an estimated mortality rate of 30%. The average household sodium intake is two times higher than the World Health Organization recommendation. The consumption of processed foods is an important and growing contributor to sodium intake. The objective of this study was to describe the sodium content of packaged foods (mg/100 g) sold in Costa Rica in 2015 (n = 1158) and 2018 (n = 1016) and to assess their compliance with the national sodium reduction targets. All 6 categories with national targets were analyzed: condiments, cookies and biscuits, bread products, processed meats, bakery products, and sauces. A significant reduction in mean sodium content was found in only 3 of the 19 subcategories (cakes, tomato-based sauces, and tomato paste). No subcategories had statistically significant increases in mean sodium levels, but seasonings for sides/mains, ham, and sausage categories were at least 15% higher in sodium. Compliance with the national sodium targets among all foods increased from 80% in 2015 to 87% in 2018. The results demonstrate that it is feasible to reduce the sodium content in packaged foods in Costa Rica, but more work is needed to continually support a gradual reduction of sodium in packaged foods, including more stringent sodium targets.

Age-Period-Cohort Analysis of Stroke Mortality Attributable to High Sodium Intake in China and Japan

Background and Purpose- The aim of this study is to assess the long-term trends in stroke mortality attributable to high sodium intake in China and Japan during the period 1990 to 2016. Methods- The mortality data were obtained from the GBD study (Global Burden of Disease) 2016 and were analyzed using an age-period-cohort method. Results- The age-standardized mortality rates showed declining trends for high sodium intake-related stroke mortality. The overall net drifts per year were -3.1% for Chinese men and -5.0% for Chinese women; and -4.6% for Japanese men and -5.7% for Japanese women. The local drift values were below zero in all age groups for both sexes in both countries, and all local drift values of female participants were below their counterparts of male participants. The longitudinal age curves of high sodium intake-attributable stroke mortality increased rapidly for both sexes in China, whereas those of Japanese were slowly rising. The period and cohort rate ratios were found to have similar downward patterns for both sexes in both countries, with a quicker decline for women than for men (significantly with P<0.05 for all). Conclusions- The age-standardized mortality rates, the period effect and the cohort effect of stroke mortality attributable to high sodium intake in China and Japan have been declining in both sexes and all age groups from 1990 to 2016. Consequently, sodium-reduction strategies are of low cost and effective for the prevention of stroke. It is necessary to educate the nation with the correct knowledge on healthy diet and techniques to reduce salt consumption.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REVIEW REGISTRATION

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

Reformulation as an Integrated Approach of Four Disciplines: A Qualitative Study with Food Companies

In 2014, the Dutch government agreed with the food sector to lower salt, sugar, saturated fat and energy in foods. To reformulate, an integrated approach of four disciplines (Nutrition & Health, Food Technology, Legislation, and Consumer Perspectives) is important for food companies (Framework for Reformulation). The objective of this study was to determine whether this framework accurately reflects reformulation processes in food companies. Seventeen Dutch food companies in the bakery, meat and convenience sector were interviewed with a semi-structured topic list. Interviews were transcribed, coded and analysed. Interviews illustrated that there were opportunities to lower salt, sugar and saturated fat (Nutrition & Health). However, there were barriers to replacing the functionality of these ingredients (Food Technology). Most companies would like the government to push reformulation more (Legislation). Traditional meat products and luxury sweet bakery products were considered less suitable for reformulation (Consumer Perspectives). In addition, the reduction of E-numbers was considered important. The important role of the retailer is stressed by the respondents. In conclusion, all four disciplines are important in the reformulation processes in food companies. Reformulation does not only mean the reduction of salt, saturated fat and sugar for companies, but also the reduction of E-numbers.

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

Background/objectives

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

Subjects/methods

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

Results

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

Conclusions

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

Identification of differences in health impact modelling of salt reduction

We examined whether specific input data and assumptions explain outcome differences in otherwise comparable health impact assessment models. Seven population health models estimating the impact of salt reduction on morbidity and mortality in western populations were compared on four sets of key features, their underlying assumptions and input data. Next, assumptions and input data were varied one by one in a default approach (the DYNAMO-HIA model) to examine how it influences the estimated health impact. Major differences in outcome were related to the size and shape of the dose-response relation between salt and blood pressure and blood pressure and disease. Modifying the effect sizes in the salt to health association resulted in the largest change in health impact estimates (33% lower), whereas other changes had less influence. Differences in health impact assessment model structure and input data may affect the health impact estimate. Therefore, clearly defined assumptions and transparent reporting for different models is crucial. However, the estimated impact of salt reduction was substantial in all of the models used, emphasizing the need for public health actions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality standards versus nutritional taxes: Health and welfare impacts with strategic firms

The goal of this paper is to better understand firms' strategic reactions to nutritional policies targeting food quality improvements and to derive optimal policies. We propose a model of product differentiation, taking into account the taste and health characteristics of products. We study how two firms react to alternative policies: an MQS policy, linear taxation of the two goods on the market, and taxation of the low-quality good. The MQS and the taxation of the low-quality product are the preferred options by a social planner. If taste is moderately important, the MQS policy is chosen by a populist and a paternalist social planner. If taste is a major component of choice, the populist planner chooses to tax the low-quality product whereas the paternalist planner prefers the MQS policy. Finally, for a paternalist social planner, an MQS-based policy always allows for higher levels of welfare than an information policy alone.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Detection of 12.5% and 25% Salt Reduction in Bread in a Remote Indigenous Australian Community

Food reformulation is an important strategy to reduce the excess salt intake observed in remote Indigenous Australia. We aimed to examine whether 12.5% and 25% salt reduction in bread is detectable, and, if so, whether acceptability is changed, in a sample of adults living in a remote Indigenous community in the Northern Territory of Australia. Convenience samples were recruited for testing of reduced-salt (300 and 350 mg Na/100 g) versus Standard (~400 mg Na/100 g) white and wholemeal breads (n = 62 for white; n = 72 for wholemeal). Triangle testing was used to examine whether participants could detect a difference between the breads. Liking of each bread was also measured; standard consumer acceptability questionnaires were modified to maximise cultural appropriateness and understanding. Participants were unable to detect a difference between Standard and reduced-salt breads (all p values > 0.05 when analysed using binomial probability). Further, as expected, liking of the breads was not changed with salt reduction (all p values > 0.05 when analysed using ANOVA). Reducing salt in products commonly purchased in remote Indigenous communities has potential as an equitable, cost-effective and sustainable strategy to reduce population salt intake and reduce risk of chronic disease, without the barriers associated with strategies that require individual behaviour change.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

High Blood Pressure among Students in Public and Private Schools in Maceió, Brazil

The prevalence of hypertension in childhood is increasing, and investigation of its distribution is important for planning timely interventions. This study assessed the prevalence of high blood pressure (HBP) and associated factors in students between 9 and 11 years of age enrolled in public and private schools in Maceió, Brazil. A cross-sectional study was performed in a probabilistic sample of students (10.3 ± 0.5 years). The students were selected from a systematic sampling of 80 schools (40 public and 40 private). To maintain similar proportions of students existing in public and private schools in Maceió, 21 and 14 students were randomly selected from each public and private school, respectively. The prevalence ratio (PR) was estimated using Poisson regression. A total of 1,338 students were evaluated (800 from public schools and 538 from private schools). No differences were observed between school types in terms of student age and gender (p > 0.05). The prevalence of obesity (19.9% vs. 9.0%; PR = 2.2; 95% CI = 1.67-2.92) and hypertension (21.2% vs. 11.4%; PR = 1.86; 95% CI = 1.45-2.40) were higher in private schools. The association between high blood pressure and type of school (public or private) remained statistically significant even after adjustment for obesity (PR = 1.53; 95% CI = 1.19-1.97).

IN CONCLUSION

(a) students from private schools have higher socioeconomic status, BMI, and HBP prevalence compared to those of public school; (b) among the evaluated students, the prevalence of obesity only partially explained the higher prevalence of high blood pressure among students from private schools. Other factors related to lifestyle of children from private schools may explain the higher prevalence of HBP. This results show the need to implement measures to promote healthy lifestyles in the school environment, since children with HBP are more likely to become hypertensive adults. Therefore, early detection and intervention in children with HBP is an important action for the prevention of hypertension in adulthood.

A Modelling Approach to Estimate the Impact of Sodium Reduction in Soups on Cardiovascular Health in the Netherlands

Hypertension is a major modifiable risk factor for cardiovascular disease and mortality, which could be lowered by reducing dietary sodium. The potential health impact of a product reformulation in the Netherlands was modelled, selecting packaged soups containing on average 25% less sodium as an example of an achievable product reformulation when implemented gradually. First, the blood pressure lowering resulting from sodium intake reduction was modelled. Second, the predicted blood pressure lowering was translated into potentially preventable incidence and mortality cases from stroke, acute myocardial infarction (AMI), angina pectoris, and heart failure (HF) implementing one year salt reduction. Finally, the potentially preventable subsequent lifetime Disability-Adjusted Life Years (DALYs) were calculated. The sodium reduction in soups might potentially reduce the incidence and mortality of stroke by approximately 0.5%, AMI and angina by 0.3%, and HF by 0.2%. The related burden of disease could be reduced by approximately 800 lifetime DALYs. This modelling approach can be used to provide insight into the potential public health impact of sodium reduction in specific food products. The data demonstrate that an achievable food product reformulation to reduce sodium can potentially benefit public health, albeit modest. When implemented across multiple product categories and countries, a significant health impact could be achieved.

Applicability of salt reduction strategies in pizza crust

In an effort to reduce population-wide sodium intake from processed foods, due to major health concerns, several different strategies for sodium reduction in pizza crust without any topping were evaluated by sensory analyses. It was possible to reduce sodium by 10% in one single step or to replace 30% of NaCl by KCl without a noticeable loss of salty taste. The late addition of coarse-grained NaCl (crystal size: 0.4-1.4 mm) to pizza dough led to an enhancement of saltiness through taste contrast and an accelerated sodium delivery measured in the mouth and in a model mastication simulator. Likewise, the application of an aqueous salt solution to one side of the pizza crust led to an enhancement of saltiness perception through faster sodium availability, leading to a greater contrast in sodium concentration. Each of these two strategies allowed a sodium reduction of up to 25% while maintaining taste quality.

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.

Health gain by salt reduction in europe: a modelling study

Excessive salt intake is associated with hypertension and cardiovascular diseases. Salt intake exceeds the World Health Organization population nutrition goal of 5 grams per day in the European region. We assessed the health impact of salt reduction in nine European countries (Finland, France, Ireland, Italy, Netherlands, Poland, Spain, Sweden and United Kingdom). Through literature research we obtained current salt intake and systolic blood pressure levels of the nine countries. The population health modeling tool DYNAMO-HIA including country-specific disease data was used to predict the changes in prevalence of ischemic heart disease and stroke for each country estimating the effect of salt reduction through its effect on blood pressure levels. A 30% salt reduction would reduce the prevalence of stroke by 6.4% in Finland to 13.5% in Poland. Ischemic heart disease would be decreased by 4.1% in Finland to 8.9% in Poland. When salt intake is reduced to the WHO population nutrient goal, it would reduce the prevalence of stroke from 10.1% in Finland to 23.1% in Poland. Ischemic heart disease would decrease by 6.6% in Finland to 15.5% in Poland. The number of postponed deaths would be 102,100 (0.9%) in France, and 191,300 (2.3%) in Poland. A reduction of salt intake to 5 grams per day is expected to substantially reduce the burden of cardiovascular disease and mortality in several European countries.

Reduced-Sodium Lunches Are Well-Accepted by Uninformed Consumers Over a 3-Week Period and Result in Decreased Daily Dietary Sodium Intakes: A Randomized Controlled Trial

BACKGROUND

Processed foods are major contributors to excessive sodium intake in Western populations. We investigated the effect of food reformulation on daily dietary sodium intake.

OBJECTIVE

To determine whether uninformed consumers accept reduced-sodium lunches and to determine the effect of consuming reduced-sodium lunches on 24-hour urinary sodium excretion.

DESIGN

A single-blind randomized controlled pretest-posttest design with two parallel treatment groups was used.

PARTICIPANTS/SETTING

Participants chose foods in an experimental real-life canteen setting at the Restaurant of the Future in Wageningen, the Netherlands, from May 16 until July 1, 2011.

INTERVENTION

After a run-in period with regular foods for both groups, the intervention group (n=36) consumed foods with 29% to 61% sodium reduction (some were partially flavor compensated). The control group (n=38) continued consuming regular foods.

MAIN OUTCOME MEASURES

Outcomes for assessment of acceptance were the amount of foods consumed, energy and sodium intake, remembered food liking, and intensity of sensory aspects. Influence on daily dietary sodium intake was assessed by 24-hour urinary sodium excretion.

STATISTICAL ANALYSES PERFORMED

Between and within-subject comparisons were assessed by analysis of covariance.

RESULTS

Energy intake and amount consumed of each food category per lunch remained similar for both groups. Compared with the control group, the intervention group's sodium intake per lunch was significantly reduced by -1,093 mg (adjusted difference) (95% CI -1,285 to -901), equivalent to 43 mmol sodium. Remembered food liking, taste intensity, and saltiness were scored similarly for almost all of the reduced-sodium foods compared with the regular foods. After consuming reduced-sodium lunches, compared with the control group, intervention participants' 24-hour urinary sodium excretion was significantly lower by -40 mEq (adjusted difference) (95% CI -63 to -16) than after consuming regular lunches, and this reflects a decreased daily sodium intake of 1 g.

CONCLUSIONS

Comparing the two treatment groups, consumption of reduced-sodium foods over a 3-week period was well accepted by the uninformed participants in an experimental real-life canteen setting. The reduced-sodium foods did not trigger compensation behavior during the remainder of the day in the intervention group compared with the control group, as reflected by 24-hour urinary sodium excretion. Therefore, offering reduced-sodium foods without explicitly informing consumers of the sodium reduction can contribute to daily sodium intake reduction.

Assessing the average sodium content of prepacked foods with nutrition declarations: the importance of sales data

Processed foods are recognized as a major contributor to high dietary sodium intake, associated with increased risk of cardiovascular disease. Different public health actions are being introduced to reduce sodium content in processed foods and sodium intake in general. A gradual reduction of sodium content in processed foods was proposed in Slovenia, but monitoring sodium content in the food supply is essential to evaluate the progress. Our primary objective was to test a new approach for assessing the sales-weighted average sodium content of prepacked foods on the market. We show that a combination of 12-month food sales data provided by food retailers covering the majority of the national market and a comprehensive food composition database compiled using food labelling data represent a robust and cost-effective approach to assessing the sales-weighted average sodium content of prepacked foods. Food categories with the highest sodium content were processed meats (particularly dry cured meat), ready meals (especially frozen pizza) and cheese. The reported results show that in most investigated food categories, market leaders in the Slovenian market have lower sodium contents than the category average. The proposed method represents an excellent tool for monitoring sodium content in the food supply.