Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet

Comparison of the effects of six-week time-restricted eating on weight loss, body composition, and visceral fat in overweight older men and women

The aim of this study was to determine the effectiveness of a six-week time-restricted eating (TRE) intervention in reducing body weight, fat loss, and visceral fat in overweight, older adult men and women (age range = 65-74 years). Another objective was to determine the feasibility of widespread use of TRE in older women and men. The study randomly assigned 116 healthy, non-smoking participants to one of two conditions: TRE or educational control participants. Participants in the TRE group were instructed to not consume calorie containing beverages or food for 16 h per day, from 8:00 pm to 12:00 pm. Participants in the control group were instructed to follow a meal plan based on their previous habits. The changes in body weight and body composition were determined using a SECA mBCA 515 analyzer. The six-week TRE intervention resulted in a significant decrease in body weight in both men and women (-1.8 kg and-1.3 kg, respectively; p = 0.03). In men, a significant decrease in visceral fat mass (-0.54 l; p ≤ 0.001) and waist circumference (-2.9 cm; p ≤ 0.015) was observed. No significant changes in either visceral fat or waist circumference were observed in women. Additionally, no change in skeletal muscle mass was observed in either the control or TRE group. More than 99 % of female and 98 % of male participants were able to adhere to the prescribed time-restricted eating (16/8) plan, suggesting that this dietary approach could have beneficial effects on the body composition of overweight older men and may also reduce body weight in overweight, older women.

The direct and indirect costs of cardiovascular diseases in Brazil

OBJECTIVE

To evaluate the direct and indirect costs of cardiovascular diseases (such as coronary heart disease and stroke) by sex and age group, attributed to the excessive consumption of salt, saturated fat and trans fat in Brazil.

MATERIALS AND METHODS

The data for estimating the Population Attributable Fraction (PAF) corresponding to the consumption of salt, saturated fat and trans-fat were obtained from the Household Budget Survey 2017-2018. The calculation of direct costs for cardiovascular diseases (CVD) was made from the accounting sum of costs with hospitalizations and outpatient care found in the National Health System (Hospital Information System and Outpatient Information System), from 2017 to 2019, including the costs of treatment, such as medical consultations, medical procedures, and drugs. Regarding the indirect costs, they were measured by the loss of human capital, given the premature death, resulting in loss of productivity. To define the attributable costs, they were multiplied by the PAF.

RESULTS

Higher burden of CVD attributable to the consumption of salt, saturated fat and trans fat were observed in younger individuals, which progressively decreased with advancing age, but still generated economic costs in the order of US$ 7.18 billion, in addition to 1.53 million productive years of life lost (YLL) to premature death, if considering salt as an inducer. Although attributable burden of CVD is higher among younger individuals, the highest costs are associated with males aged 45 to 74 years old for direct costs and 45 to 64 years old for indirect costs.

CONCLUSION

The attributable fractions to consumption of salt are the ones that cause the most effects on CVD, followed by saturated fat and trans fat, with direct and indirect costs being higher for males.

Reducing Sodium Content of Foods Served in Arkansas's Largest School District: Evaluation of the Sodium Reduction in Communities Program

Purpose and Objectives

The Centers for Disease Control and Prevention’s Sodium Reduction in Communities Program aims to reduce dietary sodium intake through policy, systems, and environmental approaches. The objective of our study was to evaluate changes in sodium levels over 5 years (2016–2021) in food served in school lunches as an outcome of a Sodium Reduction in Communities program in Arkansas’s largest school district.

Intervention Approach

We collaborated with Springdale Public Schools (SPS) to reduce dietary sodium intake in school lunches through increased implementation of 1) food service guidelines, 2) procurement practices, 3) food preparation practices, and 4) environmental strategies. These activities were maintained from year 1 through year 5. Implementation priorities were informed each year by evaluation findings from the preceding year.

Evaluation Methods

We collected lunch service records and information on nutritional content of menu items for the 30 schools under the direction of SPS’s Child Nutrition Department. We used a pretest–posttest quantitative evaluation design to analyze annual changes in the sodium content of meals, from baseline through year 5.

Results

From baseline through year 1, SPS reduced sodium served per diner, per entrée offered, and per entrée served. These reductions were maintained from baseline through 5 years of follow-up. Mean sodium per 1,000 kcal per diner served was 1,740 mg at baseline and was lower in each of the 5 follow-up years: 1,488 mg (14% decrease) in year 1; 1,495 mg (14% decrease) in year 2; 1,612 mg (7% decrease) in year 3; 1,560 mg (10% decrease) in year 4; and 1,532 mg (12% decrease) in year 5. Energy served per diner remained stable.

Implications for Public Health

Our study provides evidence for sustained sodium reduction strategies in a large ethnically and socioeconomically diverse school district, pointing to the potential benefit of implementing similar strategies in other school districts. The study also shows how program evaluation can be used to support sustainability.

Estimating the cost-effectiveness of the Sodium Reduction in Communities Program

OBJECTIVE

This study assessed the cost-effectiveness of the Centers for Disease Control and Prevention's (CDC's) Sodium Reduction in Communities Program (SRCP).

DESIGN

We collected implementation costs and performance measure indicators from SRCP recipients and their partner food service organisations. We estimated the cost per person and per food service organisation reached and the cost per menu item impacted. We estimated the short-term effectiveness of SRCP in reducing sodium consumption and used it as an input in the Prevention Impact Simulation Model to project the long-term impact on medical cost savings and quality-adjusted life-years gained due to a reduction in CVD and estimate the cost-effectiveness of SRCP if sustained through 2025 and 2040.

SETTING

CDC funded eight recipients as part of the 2016-2021 round of the SRCP to work with food service organisations in eight settings to increase the availability and purchase of lower-sodium food options.

PARTICIPANTS

Eight SRCP recipients and twenty of their partners.

RESULTS

At the recipient level, average cost per person reached was $10, and average cost per food service organisation reached was $42 917. At the food service organisation level, median monthly cost per food item impacted by recipe modification or product substitution was $684. Cost-effectiveness analyses showed that, if sustained, the programme is cost saving (i.e. the reduction in medical costs is greater than the implementation costs) in the target population by $1·82 through 2025 and $2·09 through 2040.

CONCLUSIONS

By providing evidence of the cost-effectiveness of a real-world sodium reduction initiative, this study can help inform decisions by public health organisations about related CVD prevention interventions.

Food as medicine? Exploring the impact of providing healthy foods on adherence and clinical and economic outcomes

Background

Methods

Results

Conclusion

Sodium and Health: Old Myths and a Controversy Based on Denial

Purpose of Review

The scientific consensus on which global health organizations base public health policies is that high sodium intake increases blood pressure (BP) in a linear fashion contributing to cardiovascular disease (CVD). A moderate reduction in sodium intake to 2000 mg per day helps ensure that BP remains at a healthy level to reduce the burden of CVD.

Recent Findings

Yet, since as long ago as 1988, and more recently in eight articles published in the European Heart Journal in 2020 and 2021, some researchers have propagated a myth that reducing sodium does not consistently reduce CVD but rather that lower sodium might increase the risk of CVD. These claims are not well-founded and support some food and beverage industry’s vested interests in the use of excessive amounts of salt to preserve food, enhance taste, and increase thirst. Nevertheless, some researchers, often with funding from the food industry, continue to publish such claims without addressing the numerous objections. This article analyzes the eight articles as a case study, summarizes misleading claims, their objections, and it offers possible reasons for such claims.

Summary

Our study calls upon journal editors to ensure that unfounded claims about sodium intake be rigorously challenged by independent reviewers before publication; to avoid editorial writers who have been co-authors with the subject paper’s authors; to require statements of conflict of interest; and to ensure that their pages are used only by those who seek to advance knowledge by engaging in the scientific method and its collegial pursuit. The public interest in the prevention and treatment of disease requires no less.

Reducing Sodium Intake in Community Meals Programs: Evaluation of the Sodium Reduction in Communities Program, Arkansas, 2016-2019

The Sodium Reduction in Communities Program (SRCP) aims to reduce dietary sodium intake through policy, systems, and environmental approaches. We evaluated progress of 3 years of SRCP activities in 3 community meals programs in northwest Arkansas. These activities sought to reduce dietary sodium intake through implementation of 1) food service guidelines, 2) procurement practices, 3) food preparation practices, and 4) environmental strategies. Mean reductions of 579 mg (−40%) in sodium served per diner and 525 mg (−22%) in sodium per 1,000 kcal served per diner were found from baseline to Year 1. Mean reductions of 499 mg (−35%) in sodium served per diner and 372 mg (−16%) in sodium per 1,000 kcal served per diner were sustained from baseline to Year 3. These results highlight the effectiveness and sustainability of sodium reduction interventions in community meals programs, whose diners experience food insecurity, have low incomes, and are at high risk for hypertension.

Docosahexaenoic acid (22:6 n-3)-rich microalgae along with methionine supplementation in broiler chickens: effects on production performance, breast muscle quality attributes, lipid profile, and incidence of white striping and myopathy

The effect of docosahexaenoic acid (DHA, 22:6 n-3)-rich microalgae and methionine (Met) supplementation on production performance, incidence of breast muscle white striping (WS), and pathology, lipid profile, and meat quality aspects in broiler chickens was investigated. The hypothesis tested was that feeding Met and n-3 fatty acid (FA)-rich diet enhances muscle n-3 FA content and meat quality while attenuating breast muscle WS and myopathy in broiler chickens. One hundred and forty four (n = 144) 10-day-old Cornish cross chicks were fed a corn-soybean meal-based diet containing 0% microalgae (control), 2% microalgae (diet 1), and diet 1 + 100% more National Research Council requirement of Met (diet 2) up to day 42 of growth. All diets were isocaloric and isonitrogenous. The chicks were kept in 6 pens with 8 chicks per replicate pen. Feed consumption and feed efficiency were calculated on day 21 and 42. On day 43, 3 chicks per pen (n = 18/treatment) were euthanized. The breast muscle (pectoralis major) was visually scored for muscle WS (1 = no striping, 2 = mild, 3 = severe) and was subjected to histopathology. Breast muscle lipid profile (total lipids, FA composition, cholesterol, lipid oxidation products), quality (moisture, color, drip loss, shear force, cook loss, pH), and chemical characterization (protein, minerals) were recorded. A one-way analysis of variance was carried out with diet as the main factor and significance was set at P < 0.05. The incidence of muscle WS was lower (P < 0.02) for control vs. diet 2 and a trend for reduction in WS was observed in birds fed diet 1 vs. control (P = 0.09). Histopathological changes consisted of floccular or vacuolar degeneration, fibrosis, lipidosis, interstitial inflammation, and lysis of fibers, and were minimal in diet 2 when compared to control (P < 0.05). The total lipid content was lowest in birds fed diet 1 (P < 0.05). Total n-3 and total long chain (≥20C) n-3 FA were highest in the breast muscle of diet 2 birds (P < 0.05). Muscle drip loss and shear force were highest in diet 2 (P < 0.05). Meat color (a∗, redness) was reduced (P < 0.05) and a trend for reduction in b∗ (yellowness) was observed in diet 2 (P = 0.07). No effect of diet on body weight gain, feed efficiency, breast muscle yield, pH, moisture, lipid oxidation products, cook loss, minerals (Ca, P, Mg, Na), cholesterol, or protein content was observed (P > 0.05). The results demonstrated a significant effect of DHA-rich microalgae along with Met supplementation in reducing the incidence of breast muscle striping and myopathy, while enriching meat with n-3 FA. However, inclusion of Met in microalgae-based diets could influence meat tenderness and color.

Impact of interventions to reduce overnutrition on healthcare costs related to obesity and type 2 diabetes: a systematic review

CONTEXT

In recent decades, obesity and type 2 diabetes mellitus (T2DM) have both become global epidemics associated with substantial healthcare needs and costs.

OBJECTIVE

The aim of this review was to critically assess nutritional interventions for their impact on healthcare costs to community-dwelling individuals regarding T2DM or obesity or both, specifically using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria to assess the economic components of the evidence.

DATA SOURCES

Searches were executed in Embase, EconLit, AgEcon, PubMed, and Web of Science databases.

STUDY SELECTION

Studies were included if they had a nutritional perspective, reported an economic evaluation that included healthcare costs, and focused on obesity or T2DM or both. Studies were excluded if they examined clinical nutritional preparations, dietary supplements, industrially modified dietary components, micronutrient deficiencies, or undernutrition; if they did not report the isolated impact of nutrition in complex or lifestyle interventions; or if they were conducted in animals or attempted to transfer findings from animals to humans.

DATA EXTRACTION

A systematic review was performed according to PRISMA guidelines. Using predefined search terms, 21 studies evaluating food habit interventions or taxation of unhealthy foods and beverages were extracted and evaluated using CHEERS criteria.

RESULTS

Overall, these studies showed that nutrition interventions and taxation approaches could lead to cost savings and improved health outcomes when compared with current practice. All of the included studies used external sources and economic modeling or risk estimations with population-attributable risks to calculate economic outcomes.

CONCLUSIONS

Most evidence supported taxation approaches. The effect of nutritional interventions has not been adequately assessed. Controlled studies to directly measure economic impacts are warranted.

Cardiometabolic disease costs associated with suboptimal diet in the United States: A cost analysis based on a microsimulation model

BACKGROUND

Poor diet is a leading risk factor for cardiometabolic disease (CMD) in the United States, but its economic costs are unknown. We sought to estimate the cost associated with suboptimal diet in the US.

METHODS AND FINDINGS

A validated microsimulation model (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends [CVD PREDICT]) was used to estimate annual cardiovascular disease (fatal and nonfatal myocardial infarction, angina, and stroke) and type 2 diabetes costs associated with suboptimal intake of 10 food groups (fruits, vegetables, nuts/seeds, whole grains, unprocessed red meats, processed meats, sugar-sweetened beverages, polyunsaturated fats, seafood omega-3 fats, sodium). A representative US population sample of individuals aged 35-85 years was created using weighted sampling from National Health And Nutrition Examination Surveys (NHANES) 2009-2012 cycles. Estimates were stratified by cost type (acute, chronic, drug), sex, age, race, education, BMI, and health insurance. Annual diet-related CMD costs were $301/person (95% CI $287-$316). This translates to $50.4 billion in CMD costs (18.2% of total) for the whole population, of which 84.3% are attributed to acute care ($42.6 billion). The largest annual per capita costs are attributed to low consumption of nuts/seeds ($81; 95% CI $74-$86) and seafood omega-3 fats ($76; 95% CI $70-$83), and the lowest are attributed to high consumption of red meat ($3; 95% CI $2.8-$3.5) and polyunsaturated fats ($20; 95% CI $19-$22). Individual costs are highest for men ($380), those aged ≥65 years ($408), blacks ($320), the less educated ($392), and those with Medicare ($481) or dual-eligible ($536) insurance coverage. A limitation of our study is that dietary intake data were assessed from 24-hour dietary recall, which may not fully capture a diet over a person's life span and is subject to measurement errors.

CONCLUSIONS

Suboptimal diet of 10 dietary factors accounts for 18.2% of all ischemic heart disease, stroke, and type 2 diabetes costs in the US, highlighting that timely implementation of diet policies could address these health and economic burdens.

Economic modeling for improved prediction of saving estimates in healthcare costs from consumption of healthy foods: the Mediterranean-style diet case study

Background

By design, existing scenario-based nutrition economics studies on the financial benefits of healthy dietary behaviors generally report uncertainty in inputs and wide ranges of outcome estimates.

Objectives

This modeling exercise aimed to establish precision in prediction of the potential healthcare cost savings that would follow a reduction in the incidence of cardiovascular disease (CVD) consistent with an increase in adherence to a Mediterranean-style diet (MedDiet).

Design

Using a Monte Carlo simulation model on a cost-of-illness analysis assessing MedDiet adherence, CVD incidence reduction, and healthcare cost savings in the United States and Canada, short- and long-term cost savings that are likely to accrue to the American and Canadian healthcare systems were estimated using 20 and 80% increases in MedDiet adherence scenarios.

Results

Increasing percentage of population adhering to a MedDiet by 20% beyond the current adherence level produced annual savings in CVD-related costs of US$8.2 billion (95% confidence interval [CI], $7.5-$8.8 billion) in the United States and Can$0.32 billion (95% CI, $0.29-$0.34 billion) in Canada. An 80% increase in adherence resulted in savings equal to US$31 billion (95% CI, $28.6-$33.3 billion) and Can$1.2 billion (95% CI, $1.11-$1.30 billion) in each respective country.

Conclusion

Computational techniques with stochastic parameter inputs, such as the Monte Carlo simulation, could be an effective way of incorporating variability of modeling parameters in nutrition economics studies for improved precision in estimating the monetary value of healthy eating habits.

Microbial quality of reduced-sodium napa cabbage kimchi and its processing

This study evaluated the microbial safety of reduced-sodium napa cabbage kimchi products by comparing with conventional kimchi samples. Five commercial kimchi samples were collected from different manufacturers in Korea. Total aerobic plate counts and coliforms counts between regular and reduced-sodium kimchi were not significantly (p > 0.05) different and major foodborne pathogens, including Escherichia coli O157:H7, Salmonella spp., Listeria monocytogenes, Staphylococcus aureus, and Yersinia enterocolitica were not detected in any sample. Bacillus cereus contamination among all kimchi samples was less than the regulation level (3.0 log CFU/g). However, high levels of coliforms were observed in both types of samples. To investigate microbial hazards of kimchi processing, we analyzed specific kimchi production processes and found five control points which can reduce coliform levels in kimchi samples. The results of this study could be helpful for the kimchi industry to produce safe reduced-sodium kimchi products.

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.

Habit formation intervention to prevent obesity in low-income preschoolers and their mothers: A randomized controlled trial protocol

BACKGROUND

Low-income and racial/ethnic minority mothers and their young children are at increased risk for obesity. Lack of access to evidence-based obesity prevention and treatment services further contributes to these disparities.

METHODS

This two-arm, parallel, randomized controlled trial (RCT) tests the effectiveness of a simple obesity intervention (HABITS) delivered as part of ongoing home visitation services, compared to the existing home visitation services without obesity-related content on mothers' and children's obesity risks. HABITS focuses on habit formation and modifications of food and activity cues in the home to support habit formation. Habit formation is focused on improving five behaviors: 1) fruits/vegetables, 2) fried foods, 3) sugar-sweetened beverages, 4) physical activity and 5) self-monitoring. Participants will be 298 mothers (>50% African American; 100% low income) and their children (3-5yo at baseline) enrolled in a home visitation program in central Alabama. Home visitors will be randomly assigned to deliver the home visitation curriculum with or without HABITS as part of their weekly home visits for 9 months. Assessments of mothers (weight, waist circumference, and habit strength of targeted behaviors), children (rate of weight gain), and the food/activity household environment will be conducted at enrollment, post-intervention (9 month), and one year post-intervention follow-up.

DISCUSSION

This research is poised to have a substantial impact because the delivery modalities of current obesity efforts disproportionally restrict the reach and engagement of underserved, low-income children and their caregivers who are most at-risk for health and obesity disparities.

Estimating the health and economic effects of the proposed US Food and Drug Administration voluntary sodium reformulation: Microsimulation cost-effectiveness analysis

BACKGROUND

Sodium consumption is a modifiable risk factor for higher blood pressure (BP) and cardiovascular disease (CVD). The US Food and Drug Administration (FDA) has proposed voluntary sodium reduction goals targeting processed and commercially prepared foods. We aimed to quantify the potential health and economic impact of this policy.

METHODS AND FINDINGS

We used a microsimulation approach of a close-to-reality synthetic population (US IMPACT Food Policy Model) to estimate CVD deaths and cases prevented or postponed, quality-adjusted life years (QALYs), and cost-effectiveness from 2017 to 2036 of 3 scenarios: (1) optimal, 100% compliance with 10-year reformulation targets; (2) modest, 50% compliance with 10-year reformulation targets; and (3) pessimistic, 100% compliance with 2-year reformulation targets, but with no further progress. We used the National Health and Nutrition Examination Survey and high-quality meta-analyses to inform model inputs. Costs included government costs to administer and monitor the policy, industry reformulation costs, and CVD-related healthcare, productivity, and informal care costs. Between 2017 and 2036, the optimal reformulation scenario achieving the FDA sodium reduction targets could prevent approximately 450,000 CVD cases (95% uncertainty interval: 240,000 to 740,000), gain approximately 2.1 million discounted QALYs (1.7 million to 2.4 million), and produce discounted cost savings (health savings minus policy costs) of approximately $41 billion ($14 billion to $81 billion). In the modest and pessimistic scenarios, health gains would be 1.1 million and 0.7 million QALYS, with savings of $19 billion and $12 billion, respectively. All the scenarios were estimated with more than 80% probability to be cost-effective (incremental cost/QALY < $100,000) by 2021 and to become cost-saving by 2031. Limitations include evaluating only diseases mediated through BP, while decreasing sodium consumption could have beneficial effects upon other health burdens such as gastric cancer. Further, the effect estimates in the model are based on interventional and prospective observational studies. They are therefore subject to biases and confounding that may have influenced also our model estimates.

CONCLUSIONS

Implementing and achieving the FDA sodium reformulation targets could generate substantial health gains and net cost savings.

Healthcare Expenditure and Productivity Cost Savings from Reductions in Cardiovascular Disease and Type 2 Diabetes Associated with Increased Intake of Cereal Fibre among Australian Adults: A Cost of Illness Analysis

An ageing population and growing prevalence of chronic diseases including cardiovascular disease (CVD) and type 2 diabetes (T2D) are putting increased pressure on healthcare expenditure in Australia. A cost of illness analysis was conducted to assess the potential savings in healthcare expenditure and productivity costs associated with lower prevalence of CVD and T2D resulting from increased intake of cereal fibre. Modelling was undertaken for three levels of increased dietary fibre intake using cereal fibre: a 10% increase in total dietary fibre; an increase to the Adequate Intake; and an increase to the Suggested Dietary Target. Total healthcare expenditure and productivity cost savings associated with reduced CVD and T2D were calculated by gender, socioeconomic status, baseline dietary fibre intake, and population uptake. Total combined annual healthcare expenditure and productivity cost savings of AUD$17.8 million-$1.6 billion for CVD and AUD$18.2 million-$1.7 billion for T2D were calculated. Total savings were generally larger among adults of lower socioeconomic status and those with lower dietary fibre intakes. Given the substantial healthcare expenditure and productivity cost savings that could be realised through increases in cereal fibre, there is cause for the development of interventions and policies that encourage an increase in cereal fibre intake in Australia.

Evidence of Dietary Improvement and Preventable Costs of Cardiovascular Disease

We conducted a review to summarize preventable medical costs of cardiovascular disease (CVD) associated with improved diet, as defined by the 2020 Strategic Impact Goal of the American Heart Association. We searched databases of PubMed, Embase, CINAHL and ABI/INFORM to identify population-based studies published from January 1995 to December 2015 on CVD medical costs related to excess intake of salt/sodium or sugar-sweetened beverages, and inadequate intake of fruits and vegetables, fish/fish oils/omega-3 fatty acids, or whole grains/fiber/dietary fiber. Based on the American Heart Association's secondary dietary metrics, we also searched the literature on inadequate intake of nuts and excess intake of processed meat and saturated fat. For each component, we evaluated the CVD cost savings if consumption levels were changed. The cost savings were adjusted into 2013 US dollars. Among 330 studies focusing on diet and economic consequences, 16 studies evaluated CVD costs associated with 1 or more dietary components: salt/sodium (n = 13), fruits and vegetables (n = 1), meat (n = 1), and saturated fat (n = 3). In the United States, reducing individual sodium intake to 2,300 mg/day from the current level could potentially save $1,990.9/person per year for hypertension treatment, based on a simulation study. Increasing consumption of fruits and vegetables from <0.5 cup/day to >1.5 cups/day could save $1,568.0/person per year in treatment costs for CVD, based on a cohort study. Potential CVD cost savings associated with diet improvement are substantial. Interventions for reducing sodium intake and increasing fruit and vegetable consumption could be viable means to alleviate the increasing national medical expenditures.

A Meta-Analysis to Determine the Impact of Restaurant Menu Labeling on Calories and Nutrients (Ordered or Consumed) in U.S. Adults

A systematic review and meta-analysis determined the effect of restaurant menu labeling on calories and nutrients chosen in laboratory and away-from-home settings in U.S. adults. Cochrane-based criteria adherent, peer-reviewed study designs conducted and published in the English language from 1950 to 2014 were collected in 2015, analyzed in 2016, and used to evaluate the effect of nutrition labeling on calories and nutrients ordered or consumed. Before and after menu labeling outcomes were used to determine weighted mean differences in calories, saturated fat, total fat, carbohydrate, and sodium ordered/consumed which were pooled across studies using random effects modeling. Stratified analysis for laboratory and away-from-home settings were also completed. Menu labeling resulted in no significant change in reported calories ordered/consumed in studies with full criteria adherence, nor the 14 studies analyzed with ≤1 unmet criteria, nor for change in total ordered carbohydrate, fat, and saturated fat (three studies) or ordered or consumed sodium (four studies). A significant reduction of 115.2 calories ordered/consumed in laboratory settings was determined when analyses were stratified by study setting. Menu labeling away-from-home did not result in change in quantity or quality, specifically for carbohydrates, total fat, saturated fat, or sodium, of calories consumed among U.S. adults.

Canadian Potential Healthcare and Societal Cost Savings from Consumption of Pulses: A Cost-Of-Illness Analysis

Consumption of dietary pulses, including beans, peas and lentils, is recommended by health authorities across jurisdictions for their nutritional value and effectiveness in helping to prevent and manage major diet-related illnesses of significant socioeconomic burden. The aim of this study was to estimate the potential annual healthcare and societal cost savings relevant to rates of reduction in complications from type 2 diabetes (T2D) and incidence of cardiovascular disease (CVD) following a low glycemic index (GI) or high fiber diet that includes pulses, or 100 g/day pulse intake in Canada, respectively. A four-step cost-of-illness analysis was conducted to: (1) estimate the proportions of individuals who are likely to consume pulses; (2) evaluate the reductions in established risk factors for T2D and CVD; (3) assess the percent reduction in incidences or complications of the diseases of interest; and (4) calculate the potential annual savings in relevant healthcare and related costs. A low GI or high fiber diet that includes pulses and 100 g/day pulse intake were shown to potentially yield Can$6.2 (95% CI $2.6-$9.9) to Can$62.4 (95% CI $26-$98.8) and Can$31.6 (95% CI $11.1-$52) to Can$315.5 (95% CI $110.6-$520.4) million in savings on annual healthcare and related costs of T2D and CVD, respectively. Specific provincial/territorial analyses suggested annual T2D and CVD related cost savings that ranged from up to Can$0.2 million in some provinces to up to Can$135 million in others. In conclusion, with regular consumption of pulse crops, there is a potential opportunity to facilitate T2D and CVD related socioeconomic cost savings that could be applied to Canadian healthcare or re-assigned to other priority domains. Whether these potential cost savings will be offset by other healthcare costs associated with longevity and diseases of the elderly is to be investigated over the long term.

Identifying Eating Occasion-Based Opportunities to Improve the Overall Diets of Australian Adolescents

Adolescents in Australia have a poor dietary intake, leading to large numbers of them being at risk for inadequate intake of micronutrients, and excessive intake of less healthful dietary components. This study examined dietary intakes at multiple eating occasions to identify opportunities for more targeted recommendations and strategies to improve dietary intakes among adolescents. Data from the first 24-h recall of 14-18 years old in the 2011-2012 National Nutrition and Physical Activity Survey were analysed (n = 772). Participant-defined eating occasions were classified as breakfast, lunch, dinner or other eating occasions combined. The mean percent contribution to the total day intake of top shortfall nutrients (calcium, magnesium, vitamin A, iron), discretionary calories, saturated fat, free sugars and sodium, as well as nutrient density, the foods consumed and the percent of consumers at each eating occasion, were calculated. Breakfast had the lowest prevalence of consumers (81%), contributed the least to total daily energy (14.6%) and almost a quarter of daily calcium and iron. Other eating occasions combined contributed 47.5% of free sugars and were top contributors of daily calcium (34.6%) and magnesium (31.7%). Discretionary foods contributed 32.4% of the energy at lunch, and the sodium content at lunch was 415 mg/1000 kJ. Key opportunities identified for adolescents were to increase breakfast consumption, given the high nutrient densities of breakfasts consumed; improve overall lunch quality, particularly the sodium content; promote the intake of milk, fruit and a variety of vegetables at both lunch and dinner; maintain healthful choices at in-between meal eating occasions while focusing on decreasing the intake of discretionary foods.

Influence of Cartoon Media Characters on Children's Attention to and Preference for Food and Beverage Products

BACKGROUND

Over-consuming unhealthful foods and beverages contributes to pediatric obesity and associated diseases. Food marketing influences children's food preferences, choices, and intake.

OBJECTIVE

To examine whether adding licensed media characters to healthful food/beverage packages increases children's attention to and preference for these products. We hypothesized that children prefer less- (vs more-) healthful foods, and pay greater attention to and preferentially select products with (vs without) media characters regardless of nutritional quality. We also hypothesized that children prefer more-healthful products when characters are present over less-healthful products without characters.

DESIGN

On a computer, participants viewed food/beverage pairs of more-healthful and less-healthful versions of similar products. The same products were shown with and without licensed characters on the packaging. An eye-tracking camera monitored participant gaze, and participants chose which product they preferred from each of 60 pairs.

PARTICIPANTS/SETTING

Six- to 9-year-old children (n=149; mean age=7.36, standard deviation=1.12) recruited from the Twin Cities, MN, area in 2012-2013.

MAIN OUTCOME MEASURES

Visual attention and product choice.

STATISTICAL ANALYSES PERFORMED

Attention to products was compared using paired-samples t tests, and product choice was analyzed with single-sample t tests. Analyses of variance were conducted to test for interaction effects of specific characters and child sex and age.

RESULTS

Children paid more attention to products with characters and preferred less-healthful products. Contrary to our prediction, children chose products without characters approximately 62% of the time. Children's choices significantly differed based on age, sex, and the specific cartoon character displayed, with characters in this study being preferred by younger boys.

CONCLUSIONS

Results suggest that putting licensed media characters on more-healthful food/beverage products might not encourage all children to make healthier food choices, but could increase selection of healthy foods among some, particularly younger children, boys, and those who like the featured character(s). Effective use likely requires careful demographic targeting.

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.

Pre-germinated brown rice prevented high fat diet induced hyperlipidemia through ameliorating lipid synthesis and metabolism in C57BL/6J mice

Pre-germinated brown rice (PGBR) can ameliorate hyperlipidemia, but the action mechanism is not clear. We focus the mechanisms of PGBR prevented hyperlipidemia. Six-week-old mice were divided into: standard-regular diet (SRD), high-fat diet (HFD) and HFD with PGBR (HFD + PGBR) groups for 16 weeks. The HFD group has higher concentrations of TG, TC, HDL and Non-HDL in the blood, and a higher atherosclerosis index (AI). The TG levels in the liver, and TG, bile acid levels in the feces were enhanced; and the total adipocytokines level in adipose tissue was reduced. The HFD group had higher protein expressions of SREBP-1, SCD-1, FAS, LDLR, and CYP7α1 in the liver. Moreover, the greater expressions of SREBP-1, SCD-1, FAS and the less expressions of PPAR-α and adiponectin were in adipose tissue. In the HFD + PGBR group, the PGBR regulated the levels of TG, TC, HDL, Non-HDL, AI and adipocytokines. PGBR increased more cholesterol and bile acid exhaust in feces. The SREBP-1, SCD-1, FAS, HMGCR, LDLR, CYP7α1 and PPAR-α proteins in the liver; and the SREBP-1, SCD-1, FAS, PPAR-α and adiponectin proteins in adipose tissue were reversed by PGBR. Taken together, PGBR can improve lipid synthesis and metabolism, and we suggest PGBR is a recommendable food for controlling hyperlipidemia.

A Systematic Review of the Prevalence and Outcomes of Ideal Cardiovascular Health in US and Non-US Populations

Several population-based studies have examined the prevalence and trends of the American Heart Association's ideal cardiovascular health (CVH) metrics as well as its association with cardiovascular disease (CVD)-related morbidity and mortality and with non-CVD outcomes. However, no efforts have been made to aggregate these studies. Accordingly, we conducted a systematic review to synthesize available data on the distribution and outcomes associated with ideal CVH metrics in both US and non-US populations. We conducted a systematic search of relevant studies in the MEDLINE and CINAHL databases, as well as the Cochrane Register of Controlled Trials (CENTRAL). Search terms used included "life's simple 7", "AHA 2020" and "ideal cardiovascular health". We included articles published in English Language from January 1, 2010, to July 31, 2015. Of the 14 US cohorts, the prevalence of 6 to 7 ideal CVH metrics ranged from as low as 0.5% in a population of African Americans to 12% in workers in a South Florida health care organization. Outside the United States, the lowest prevalence was found in an Iranian study (0.3%) and the highest was found in a large Chinese corporation (15%). All 6 mortality studies reported a graded inverse association between the increasing number of ideal CVH metrics and the all-cause and CVD-related mortality risk. A similar relationship between ideal CVH metrics and incident cardiovascular events was found in 12 of 13 studies. Finally, an increasing number of ideal CVH metrics was associated with a lower prevalence and incidence of non-CVD outcomes such as cancer, depression, and cognitive impairment. The distribution of ideal CVH metrics in US and non-US populations is similar, with low proportions of persons achieving 6 or more ideal CVH metrics. Considering the strong association of CVH metrics with both CVD and non-CVD outcomes, a coordinated global effort for improving CVH should be considered a priority.

Dietary fibre intakes and reduction in functional constipation rates among Canadian adults: a cost-of-illness analysis

BACKGROUND

Evidence-based research highlights beneficial impacts of dietary fibre on several aspects of the gut pathophysiology that are accompanied by a considerable financial burden in healthcare services. Recommended intakes of dietary fibre may thus associate with financial benefits at a population level.

OBJECTIVE

We sought to systematically assess the potential annual savings in healthcare costs that would follow the reduction in rates of functional constipation and irregularity with increased dietary fibre intakes among Canadian adults.

DESIGN

A cost-of-illness analysis was developed on the basis of current and recommended levels of fibre intake in Canada, constipation reduction per 1 g fibre intake, proportion of adults who are likely to consume fibre-rich diets, and population expected to respond to fibre intake. Sensitivity analyses covering a range of assumptions were further implemented within the economic simulation.

RESULTS

Our literature searches assumed a 1.8% reduction in constipation rates with each 1 g/day increase in fibre intake. With intakes corresponding to the Institute of Medicine's adequate levels of 38 g/day for men and 25 g/day for women, among 5 and 100% of the adult populations, anywhere between CAD$1.5 and CAD$31.9 million could be saved on constipation-related healthcare costs annually. Each 1 g/day increase in dietary fibre was estimated to result in total annual healthcare cost savings that ranged between CAD$0.1 and CAD$2.5 million.

CONCLUSIONS

The present research suggests an economic value of increasing dietary fibre intake beyond its well-known health benefits. Healthy-eating behaviours consistent with the recommended intakes of dietary fibre by the general public should hence be advocated as a practical approach for reducing costs associated with the management of constipation in Canada.

Nutrition and health technology assessment: when two worlds meet

There is a growing recognition that nutrition may have a positive impact on public health and that it may reduce medical expenditures. Yet, such claims need to be substantiated by evidence. This evidence could be delivered by health technology assessment (HTA), which can be thought of as the evaluation of technologies for clinical effectiveness, cost-effectiveness, and ethical, legal, and social impacts. The application of HTA to the field of “nutrition interventions” is recent. So far, HTA and nutrition have represented two worlds far apart in many respects. This contribution, roughly, addresses the following issues: is there a need for HTAs in the field of nutrition, what would such HTAs look like, and how can the results coming from these HTAs optimally aid policy making?

In essence, HTAs of nutrition have much of the same basic principles and structure as HTAs of “classical” health care treatments. Nevertheless, there are challenges to rigorous HTAs of nutrition interventions, for various reasons. To mention a few: the evidence base for nutrition interventions is less well developed than that for many health care treatments. Furthermore, it is a matter of debate which outcome measures should be used in HTAs of nutrition. For example, one may argue that nutrition not only has health effects, but also effects that are not captured by traditional health-related quality of life measures (e.g., the pleasure of eating, effects relating to ease of use, or effects on well-being).

HTAs in the field of nutrition may deliver information valuable to a wide range of stakeholders, including consumers/patients, health professionals, hospital administrators, insurers, and decision makers. The results of HTAs are typically used in making treatment guidelines, in informing decisions about reimbursement or about public health campaigns, etc. Yet, it is uncertain how the results of HTAs of nutrition can be used optimally. For example, would it be possible to summarize the results of a HTA in a single ratio (such as costs per quality-adjusted life-year gained) and then to either approve or reject the intervention based on this ratio, compared to a certain threshold? Apart from that, in the field of nutrition, it is typically not about reimbursement of a technology. Related to this, it is important that the message from HTAs of nutrition is brought to a range of stakeholders including the general population and that these HTAs are tailored to the decision-making context.

To conclude, a growing need is felt for HTA-type evaluations of nutrition, which are sparse these days. Little thought has been given to developing an optimal methodology for HTAs of nutrition and to how its results should be integrated into policy making. Further work in these areas would stimulate the development of nutrition interventions that yield a gain in societal welfare. To achieve this, the two worlds of HTA and nutrition need to be brought together.

Cost-of-illness analysis reveals potential healthcare savings with reductions in type 2 diabetes and cardiovascular disease following recommended intakes of dietary fiber in Canada

BACKGROUND

Type 2 diabetes (T2D) and cardiovascular disease (CVD) are leading causes of mortality and two of the most costly diet-related ailments worldwide. Consumption of fiber-rich diets has been repeatedly associated with favorable impacts on these co-epidemics, however, the healthcare cost-related economic value of altered dietary fiber intakes remains poorly understood. In this study, we estimated the annual cost savings accruing to the Canadian healthcare system in association with reductions in T2D and CVD rates, separately, following increased intakes of dietary fiber by adults.

METHODS

A three-step cost-of-illness analysis was conducted to identify the percentage of individuals expected to consume fiber-rich diets in Canada, estimate increased fiber intakes in relation to T2D and CVD reduction rates, and independently assess the potential annual savings in healthcare costs associated with the reductions in rates of these two epidemics. The economic model employed a sensitivity analysis of four scenarios (universal, optimistic, pessimistic, and very pessimistic) to cover a range of assumptions within each step.

RESULTS

Non-trivial healthcare and related savings of CAD$35.9-$718.8 million in T2D costs and CAD$64.8 million-$1.3 billion in CVD costs were calculated under a scenario where cereal fiber was used to increase current intakes of dietary fiber to the recommended levels of 38 g per day for men and 25 g per day for women. Each 1 g per day increase in fiber consumption resulted in annual CAD$2.6 to $51.1 million savings for T2D and $4.6 to $92.1 million savings for CVD.

CONCLUSION

Findings of this analysis shed light on the economic value of optimal dietary fiber intakes. Strategies to increase consumers' general knowledge of the recommended intakes of dietary fiber, as part of healthy diet, and to facilitate stakeholder synergy are warranted to enable better management of healthcare and related costs associated with T2D and CVD in Canada.

WHO's supported interventions on salt intake reduction in the sub-Saharan Africa region

Reduction of salt intake is an important and cost-effective way for reducing hypertension and the risk of cardiovascular diseases (CVDs). Current global salt intakes are estimated at around 10 g/day, well above the World Health Organization (WHO) recommended level of <5 g/day. The sub-Saharan Africa (SSA) region has a prevalence of hypertension of 46% among adults aged 25 and over and therefore strategies to reduce salt intake are necessary. This requires an understanding of salt intake behaviors in the population along with government commitment to increase awareness and take actions that would create an enabling environment. It is also important to have the food industry and other key stakeholders on board. A review of the developed WHO's norms and guidelines, technical support provided to countries by WHO as well as country initiatives shows that countries in the African region are at different stages in the implementation of salt reduction interventions. For example, South Africa has enacted legislation to make the food industry reduce the salt content of a number of its products while Mauritius is requesting bakery owners to reduce salt in bread. A number of countries are currently undertaking studies to measure salt intake in the populations. Overall progress is slow as the region experiences a double burden of communicable and noncommunicable diseases, competing health priorities and limited resources for health.

The impact of a Web-based app (eBalance) in promoting healthy lifestyles: randomized controlled trial

Background

The use of Web-based apps to promote a healthy lifestyle is increasing, although most of these programs were not assessed using suitable epidemiological methods. We evaluated the effectiveness of a newly developed Web-based app in promoting a healthy lifestyle and educating adults on such lifestyles. We also analyzed predictors for success in acquiring and maintaining a healthy lifestyle.

Objective

Our aim was to compare people receiving a new Web-based app with people who got an introductory lecture alone on healthy lifestyle, weight change, nutritional knowledge, and physical activity, and to identify predictors of success for maintaining a healthy lifestyle.

Methods

Subjects were recruited from the community and were randomized into intervention and control groups. The intervention subjects received access to the app without any face-to-face support; the control subjects continued their standard lifestyle. Measurements were taken by the researcher at baseline and after 14 weeks and included weight and waist circumference. Nutritional knowledge, diet quality, and physical activity duration were obtained using online questionnaires. The new Web-based app was developed based on current US Department of Agriculture and Israel Ministry of Health recommendations for healthy lifestyle. The app provides tools for monitoring diet and physical activity while instructing and encouraging healthy diet and physical activity.

Results

Out of 99 subjects who were randomized into app and control groups, 85 participants (86%) completed the study, 56 in the intervention and 29 in the control group. The mean age was 47.9 (SD 12.3) years, and mean Body Mass Index was 26.2 (SD 3.9). Among the intervention group only, frequency of app use was 2.7 (SD 1.9) days/week. The mean change in physical activity was 63 (SD 20.8) minutes in the app group and -30 (SD 27.5) minutes in the control group (P=.02). The mean weight change was -1.44 (SD 0.4) kg in the app group and -0.128 (SD 0.36) kg in the control group (P=.03). Knowledge score increased significantly in the app group, 76 (SD 7.5) to 79 (SD 8.7) at the end of the study (P=.04) compared with the control group. Diet quality score also increased significantly at the end of the study, from 67 (SD 9.8) to 71 (SD 7.6; P<.001) in contrast to the control group. Success score (represents the success in maintaining healthy lifestyle) was higher among the app group (68%) compared with 36% in the control group (P<.001). The app frequency of use was significantly related to a higher success score (P<.001).

Conclusions

We showed a positive impact of a newly developed Web-based app on lifestyle indicators during an intervention of 14 weeks. These results are promising in the app’s potential to promote a healthy lifestyle, although larger and longer duration studies are needed to achieve more definitive conclusions.

Trial Registration

Clinicaltrial.gov number: NCT01913496; http://www.clinicaltrials.gov/ct2/show/NCT01913496 (Archived by WebCite at http://www.webcitation.org/6WSTUEPuJ).

Progress on salt reduction in the Pacific Islands: from strategies to action

BACKGROUND

Most populations are consuming too much salt which is the main contributor of high blood pressure, a leading risk factor of cardiovascular disease and stroke. The South Pacific Office of the World Health Organization has been facilitating the development of salt reduction strategies in Pacific Island Countries and areas (PICs). The objective of this analysis was to review progress to date and identify regional actions needed to support PICs and ensure they achieve the global target to reduce population salt intake by 30% by 2025.

METHODS

Relevant available national food, health and non-communicable disease (NCD) plans from all 22 PICs were reviewed. NCD co-ordinators provided updates and relayed experiences through semi-structured interviews. All activities were systematically categorised according to an existing salt reduction framework for the development of salt reduction strategies.

RESULTS

Salt reduction consultations had been held in 14 countries and final strategies or action plans developed in nine of these, with drafts available in a further three. Three other countries had integrated salt reduction into NCD strategic plans. Baseline monitoring of salt intake had been undertaken in three countries, salt levels in foods in nine countries and salt knowledge, attitude and behaviour surveys in four countries. Most countries were at early stages of implementation and identified limited resources as a barrier to action. Planned salt reduction strategies included work with food industry or importers, implementing regional salt reduction targets, reducing salt levels in school and hospital meals, behaviour change campaigns, and monitoring and evaluation.

CONCLUSIONS

There had been good progress on salt reduction planning in PICs. The need for increased capacity to effectively implement agreed activities, supported by regional standards and the establishment of improved monitoring systems, were identified as important steps to ensure the potential cardiovascular health benefits of salt reduction could be fully realised in the region.

Critical review of economic evaluation studies of interventions promoting low-fat diets

Various national and local policies encouraging healthy eating have recently been proposed. The present review aims to summarize and critically assess nutrition-economic evaluation studies of direct (e.g., diet counseling) and indirect (e.g., food labeling) interventions aimed at improving dietary habits. A systematic literature review was performed by searching 5 databases (PubMed, Ovid Medline, EconLit, Agricola, and Embase) using a combination of diet-related (fat, diet, intake, nutrition) and economics-related (cost-effectiveness, cost-benefit, cost-utility, health economics, economic evaluation) key words. The search yielded 36 studies that varied in target population, study design, economic evaluation method, and health/economic outcome. In general, all provide limited experimental evidence and adopt the framework of economic evaluations in healthcare. Certain important aspects were not well considered: 1) the non-health-related effects of nutrition interventions on well-being; 2) the private nature of food expenditures; 3) the distributional effects on food expenditures across socioeconomic groups; and 4) the general economic implications (e.g., agrofoods, import/export) of such interventions. Overall, the methodology for the economic evaluation of nutrition interventions requires substantial improvement.

Effect of soy isoflavones on thyroid hormones in intact and ovariectomized cynomolgus monkeys (Macaca fascicularis)

OBJECTIVE

Soy isoflavones are commonly used to alleviate menopause-related symptoms. Postmenopausal women are at increased risk for hypothyroidism, and there are concerns that isoflavones may be detrimental to thyroid health. The aim of this study was to examine the effects of soy protein and isoflavones on thyroid function and the relationship between thyroid function and ovarian function.

METHODS

Adult female cynomolgus monkeys (Macaca fascicularis) were randomized to consume two diets differing only in protein source: casein-lactalbumin (n = 44) or soy protein with isoflavones (n = 41). After 34 months, all animals were ovariectomized via laparotomy. Half of the monkeys from each diet treatment group continued to consume their preovariectomy treatment phase diet (either isolated soy protein [n = 19] or casein-lactalbumin [n = 21]) for an additional 34 months. The remaining animals did not continue their diets and thus were not considered further. Circulating progesterone, triiodothyronine, thyroxine, and thyroid-stimulating hormone were measured at baseline. Thyroid hormones were remeasured during each treatment phase.

RESULTS

Dietary soy increased triiodothyronine in preovariectomized monkeys and prevented a decline in thyroxine after surgical menopause (both P's < 0.05). Mean progesterone concentrations were positively correlated with triiodothyronine at baseline in preovariectomized monkeys (P < 0.01).

CONCLUSIONS

Progesterone levels and triiodothyronine are positively correlated in macaques. Dietary soy increases triiodothyronine in preovariectomized monkeys and prevents a decline in thyroxine after surgical menopause. The outcomes observed in this study suggest that soy protein and isoflavone consumption does not adversely affect-and may even preserve-thyroid function in postmenopausal women.

Potential effect of salt reduction in processed foods on health

BACKGROUND

Excessive salt intake has been associated with hypertension and increased cardiovascular disease morbidity and mortality. Reducing salt intake is considered an important public health strategy in the Netherlands.

OBJECTIVE

The objective was to evaluate the health benefits of salt-reduction strategies related to processed foods for the Dutch population.

DESIGN

Three salt-reduction scenarios were developed: 1) substitution of high-salt foods with low-salt foods, 2) a reduction in the sodium content of processed foods, and 3) adherence to the recommended maximum salt intake of 6 g/d. Health outcomes were obtained in 2 steps: after salt intake was modeled into blood pressure levels, the Chronic Disease Model was used to translate modeled blood pressures into incidences of cardiovascular diseases, disability-adjusted life years (DALYs), and life expectancies. Health outcomes of the scenarios were compared with health outcomes obtained with current salt intake.

RESULTS

In total, 4.8% of acute myocardial infarction cases, 1.7% of congestive heart failure cases, and 5.8% of stroke cases might be prevented if salt intake meets the recommended maximum intake. The burden of disease might be reduced by 56,400 DALYs, and life expectancy might increase by 0.15 y for a 40-y-old individual. Substitution of foods with comparable low-salt alternatives would lead to slightly higher salt intake reductions and thus to more health gain. The estimates for sodium reduction in processed foods would be slightly lower.

CONCLUSION

Substantial health benefits might be achieved when added salt is removed from processed foods and when consumers choose more low-salt food alternatives.

Recent economic evaluations of interventions to prevent cardiovascular disease by reducing sodium intake

Excess intake of sodium, a common problem worldwide, is associated with hypertension and cardiovascular disease (CVD), and hypertension is a major risk factor for CVD. Population-wide efforts to reduce sodium intake have been identified as a promising strategy for preventing hypertension and CVD, and such initiatives are currently recommended by a variety of scientific and public health organizations. By reviewing the literature published from January 2011 to March 2013, we summarized recent economic analyses of interventions to reduce sodium intake. The evidence, derived from estimates of resultant blood pressure decreases and thus decreases in the incidence of CVD events, supports population-wide interventions for reducing sodium intake. Both lowering the salt content in manufactured foods and conducting mass media campaigns at the national level are estimated to be cost-effective in preventing CVD. Although better data on the cost of interventions are needed for rigorous economic evaluations, population-wide sodium intake reduction can be a promising approach for containing the growing health and economic burden associated with hypertension and its sequelae.

Food sources of sodium, saturated fat and added sugar in the Spanish hypertensive and diabetic population

OBJECTIVES

Previous research has shown that the diet of hypertensive and diabetic patients has a low accordance with the main nutritional recommendations, mostly due to the high intake of sodium, saturated fat and added sugars. This is the first study to identify the main food sources of these nutrients in these patients.

METHODS

Cross-sectional study conducted in 2008-2010 in a representative sample of the Spanish adult population, including 2323 patients with hypertension and 635 with diabetes. The habitual diet was assessed using a validated diet history. The intake of sodium, saturated fat and added sugars was estimated with Spanish food composition tables.

RESULTS

The hypertensive and diabetic population showed, respectively, an intake of 2.9 and 3.1 g/day of sodium, 26 and 26 g/day of saturated fat, and 33 and 24 g/day of added sugar. In hypertensive and diabetic patients, respectively, most sodium intake came from bread (35%, 34%), raw-cured sausages (15%, 15%), cooked sausages (6%, 7%), and soup (5%, 6%). The main sources of saturated fat were cured cheese (13%, 13%), bakery products (12%, 11%), red meat (10%, 11%), raw-cured sausages (8%, 9%) and whole milk (4%, 4%). The food groups that most contributed to added sugar intake were sugar directly added to coffee and other beverages (27%, 19%), bakery products (15%, 19%), sugary soft drinks (10%, 13%), and whole yogurt (9%, 12%). The main food sources of nutrients were similar in all sex and age groups.

CONCLUSIONS

In patients with hypertension and diabetes, the intake of sodium, saturated fat and added sugar can be substantially reduced by prioritizing low-salt varieties of bread, reducing the consumption of bakery products and sausages, replacing cured cheese and other whole dairy products by low-fat products, using non-sugary sweeteners, and substituting sugar-free soft drinks, or plain water, for sugary sodas.

Spatial variation of salt intake in Britain and association with socioeconomic status

OBJECTIVES

To evaluate spatial effects of variation and social determinants of salt intake in Britain.

DESIGN

Cross-sectional survey.

SETTING

Great Britain.

PARTICIPANTS

2105 white male and female participants, aged 19-64 years, from the British National Diet and Nutrition Survey 2000-2001.

PRIMARY OUTCOMES

Participants' sodium intake measured both with a 7-day dietary record and a 24-h urine collection. By accounting for important linear and non-linear risk factors and spatial effects, the geographical difference and spatial patterns of both dietary sodium intake and 24-h urinary sodium were investigated using Bayesian geo-additive models via Markov Chain Monte Carlo simulations.

RESULTS

A significant north-south pattern of sodium intake was found from posterior probability maps after controlling for important sociodemographic factors. Participants living in Scotland had a significantly higher dietary sodium intake and 24-h urinary sodium levels. Significantly higher sodium intake was also found in people with the lowest educational attainment (dietary sodium: coeff. 0.157 (90% credible intervals 0.003, 0.319), urinary sodium: 0.149 (0.024, 0.281)) and in manual occupations (urinary sodium: 0.083 (0.004, 0.160)). These coefficients indicate approximately a 5%, 9% and 4% difference in average sodium intake between socioeconomic groups.

CONCLUSIONS

People living in Scotland had higher salt intake than those in England and Wales. Measures of low socioeconomic position were associated with higher levels of sodium intake, after allowing for geographic location.

Nutrition standards for away-from-home foods in the USA

Away-from-home foods are regulated with respect to the prevention of food-borne diseases and potential contaminants, but not for their contribution to dietary-related chronic diseases. Away-from-home foods have more calories, salt, sugar and fat, and include fewer fruits and vegetables than recommended by national nutrition guidelines. Thus, frequent consumption of away-from-home foods contributes to obesity, hypertension, diabetes, heart disease, and cancer. In light of this, many localities are already adopting regulations or sponsoring programs to improve the quality of away-from-home foods. We review the rationale for developing nutritional performance standards for away-from-home foods in light of limited human capacity to regulate intake or physiologically compensate for a poor diet. We offer a set of model performance standards to be considered as a new area of environmental regulation. Models for voluntary implementation of consumer standards exist in the environmental domain and may be useful templates for implementation. Implementing such standards, whether voluntarily or via regulations, will require addressing a number of practical and ideological challenges. Politically, regulatory standards contradict the belief that adults should be able to navigate dietary risks in away-from-home settings unaided.

Multiple health behaviours: overview and implications

BACKGROUND

More remains unknown than known about how to optimize multiple health behaviour change.

METHODS

After reviewing the prevalence and comorbidities among major chronic disease risk behaviours for adults and youth, we consider the origins and applicability of high-risk and population strategies to foster multiple health behaviour change.

RESULTS

Findings indicate that health risk behaviours are prevalent, increase with age and co-occur as risk behaviour clusters or bundles.

CONCLUSIONS

We conclude that both population and high-risk strategies for health behaviour intervention are warranted, potentially synergistic and need intervention design that accounts for substitute and complementary relationships among bundled health behaviours. To maximize positive public health impact, a pressing need exists for bodies of basic and translational science that explain health behaviour bundling. Also needed is applied science that elucidates the following: (1) the optimal number of behaviours to intervene upon; (2) how target behaviours are best selected (e.g. greatest health impact; patient preference or positive effect on bundled behaviours); (3) whether to increase healthy or decrease unhealthy behaviours; (4) whether to intervene on health behaviours simultaneously or sequentially and (5) how to achieve positive synergies across individual-, group- and population-level intervention approaches.

Low-sodium meat products: retaining salty taste for sweet health

There is a positive correlation between excessive intake of sodium and incidence of hypertension. As diet is the main source of sodium, awareness among people regarding its possible role upon health has driven demand for various low sodium foods including meat products. Meat products contribute a significant amount of dietary sodium, thus maligning their own image. However, this is not an easy task as common salt affects taste and flavor, functional attributes, stability, and food safety of meat products. The various properties such as taste and flavor, binding, as well as microbiological characteristics should be given due care while developing low salt meat products and accordingly different approaches have been proposed for processing of such products. Potassium chloride has been mostly used to replace sodium; however, a number of other salts, flavor enhancers, bitter blockers and water, as well as fat binders have also been attempted either alone or in different combinations. A number of low sodium meat products have been developed but their economy and consumer acceptability are the major concerns needing proper attention. In future it is anticipated that these challenges would be overcome to provide well acceptable and cost-effective healthier meat products to the consumers.