Assessing the Policy Landscape for Salt Reduction in South-East Asian and Latin American Countries - An Initiative Towards Developing an Easily Accessible, Integrated, Searchable Online Repository

Cost-effectiveness analysis of low-sodium potassium-rich salt substitutes in Indonesia: an equity modelling study

Background

Evidence suggests low-sodium potassium-rich salt substitutes (LSSS) are effective in reducing blood pressure (BP). However, the health and economic impacts of LSSS in Indonesia are currently unknown.

Methods

We developed a proportional multistate lifetable Markov model to assess a government-led strategy implementing the use of LSSS compared to current regular salt consumption. BP data were derived from the Indonesian Basic Health Research Survey (RISKESDAS 2018), while epidemiological data were from the Global Burden of Disease 2019 study. We estimated implementation costs and the impact of changes in BP on disease events and healthcare costs, and incremental cost-effectiveness ratios. Outcomes were simulated over different time horizons for the 2019 Indonesian population overall, and by income quintiles. Probabilistic sensitivity analysis was done to capture uncertainty.

Findings

Over the first 10 years, LSSS could prevent 1.5 million non-fatal cardiovascular disease (CVD) events (8.3%-19.4% reduction) and 643,000 incident chronic kidney disease (CKD) cases (8.2% reduction), while averting over 200,000 CVD and CKD deaths (0.2%-5.2% reduction). This translated to over 24.6 million health-adjusted life years (HALYs) gained over the lifetime of the population, and reduced CVD-related health inequalities (concentration index, -0.075, 95% CI: -0.088 to -0.062). Implementation cost (US$ 1.2 billion [IDR 17.2 trillion] total; US$ 4.5 [IDR 63,665] per capita, as of July 2019) was outweighed by the net health expenditure savings (∼US$ 2 billion [IDR 27.7 trillion] total; US$ 7.3 [IDR 103,300] per capita) in the first 10 years. LSSS were cost-saving over the lifetime, and very cost-effective even with a high LSSS price.

Interpretation

Scaling the use of LSSS nationally could be a cost-saving strategy to prevent substantial cardiovascular and kidney disease burden in Indonesia.

Funding

Griffith University Postdoctoral Fellowship.

Perceptions, barriers and enablers of salt reduction in Malaysian out-of-home sectors (MySaltOH): from the point of view of policy-makers and food industries

BACKGROUND

High salt intake is a major cause of hypertension and cardiovascular diseases. The out-of-home sectors have been identified as one of the contributors of high salt intake in the population. The National Salt Reduction Policy of Malaysia was initiated in 2015; however, out-of-home sectors are yet to be emphasized and perception by policy-makers and the food industries towards salt reduction are yet unknown. This study aimed to determine the perceptions, barriers and enablers towards salt reduction in the out-of-home sector in Malaysia, as well as among policy-makers and the food industries.

METHODS

This is a qualitative study via semi-structured in-depth interviews (IDI) and focus group discussions (FGD) involving several stakeholders consisting of policy-makers from five ministries, five nongovernment organizations (NGOs) and food science/food technology researchers from five regions (West, North, East, and South Peninsular and East Malaysia/Borneo), as well as the food industries. The IDI and FGD sessions were recorded, transcribed verbatim and analysed thematically using Nvivo software version 12.

RESULTS

All participants agreed that salt intake in Malaysia is high and leads to hypertension and cardiovascular diseases. Lack of awareness, poor eating culture and behaviour and frequent eating out were among the causes of high salt intake. Awareness campaigns and education, sodium content labelling and product reformulation were strategies that have been implemented by the government; whilst for the food industries, some of them have tried to reduce salt and labelled the sodium content on their food products. However, there were several barriers including perceived poor consumer acceptance, lack of knowledge and resources, and challenges in reformulation, as well as unavailability of guidelines and salt targets. Hence, several enablers have been suggested, which include prioritizing the salt reduction strategy, creating more awareness, collaboration and engagement, research and technology particularly for reformulation and shelf-life stability, incentives and salt tax.

CONCLUSIONS

Salt reduction efforts of the out-of-home sector in Malaysia could be achieved through several measures or enablers that can overcome the barriers currently faced by stakeholders, especially policy-makers, food industries and the consumers themselves. This study will benefit the policy-makers to improve the salt reduction policy of out-of-home sectors and highlight the concerns among the food industries on the policy.