This article has Open Peer Review reports available.
Modeling health gains and cost savings for ten dietary salt reduction targets
© Wilson et al. 2016
Received: 27 January 2016
Accepted: 15 April 2016
Published: 26 April 2016
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.
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.
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).
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.
A diet high in sodium is ranked as the second most important dietary risk factor to health globally  and salt reduction is included in the top five priority actions for non-communicable disease (NCD) control internationally . The World Health Organization (WHO) has a “strong recommendation” for countries to aim for a 30 % relative reduction in dietary intakes towards 5 g/day of salt .
While there are some persisting concerns around the relationship between dietary salt intake and health outcomes, the totality of the evidence is likely to justify public health action (as some of us have discussed elsewhere ). There are also several recent publications that add further weight to the adverse impact of dietary salt on health [5–10]. Even when the theoretical minimum level of risk exposure of sodium intake is modeled with wide uncertainty (from 1000 to 5000 mg of dietary sodium per day), it resulted in dietary sodium being ranked as the 11th most important risk factor to health globally in the Global Burden of Disease 2013 Study .
Health impact and health economic modeling studies of population-level dietary salt reduction interventions involving reductions in sodium in processed foods (for publications from 1 January 2010 up to the end of June 2015 and ordered by publication year)
Setting and reference
Interventions aimed at specific foods/food categories
Australia, Cobiac et al 2010 
Voluntary and mandatory reduction of salt content in breads, margarine, and cereals.
Both were cost-saving interventions but health gain was much greater for the mandatory vs voluntary intervention (e.g., 110,000 vs 5300 disability-adjusted life-years [DALYs] averted).
US, Smith-Spangler et al 2010 
Voluntary collaboration with industry was assumed to decrease sodium intake by the same amount as reported for the UK (9.5 %), with a range of 5 to 40 %.
Large health gain of 2.1 million QALYs, and savings in medical costs of $US32.1 billion (both over the cohort’s lifetime). Large benefits were seen with a salt tax.
Argentina, Rubinstein et al 2010 
Voluntary reduction of salt content in bread by 1 g salt per 100 g.
Relatively small averted DALYs (compared to other CVD interventions) but still a cost-saving intervention. An earlier result by this team identified this intervention as cost-effective at ARS$151 (US$28) per DALY averted .
South Africa, Bertram et al 2012 
Regulations to reduce the sodium content of bread, soup mix, seasoning and margarine (a reduction in salt of 0.85 g/person/day).
Substantial reduction in CVD deaths and non-fatal strokes estimated. Cost savings “of up to R300 million would also occur” (US$128 million).
Australia, Cobiac et al 2012 
Mandatory reduction of salt content in breads, margarine, and cereals.
Large number of DALYs averted per year (80,000) and cost-saving. (See also a similar study listed above by these authors).
Argentina, Konfino et al 2013 
Voluntary initiative currently in place in Argentina for 5 to 15 % reductions of sodium in: (i) processed meats, (ii) cheese and dairy products, (iii) soups and dressings and (iv) cereals, cookies, pizza and pasta.
Large reductions in: all-cause mortality, myocardial infarctions, and strokes, especially if the 2 year program agreed to with industry was extended to a larger 10 year one. (But no cost data included).
Netherlands, Hendriksen et al 2014 
Theoretical reduction in salt in processed foods (variable by food category – but averaging 50 % reduction).
The median salt intake was expected to decrease by 28 % and blood pressure by 1.2 %. An estimated 256,000 DALYs were averted (239,700 to 272,300) and 0.15 per capita life years gained (0.11–0.19) among 40 year olds over the rest of their lifetimes.
New Zealand, Nghiem et al 2015 
Mandatory 25 % reduction of salt in bread, processed meats and sauces. Also a voluntary endorsement label program (covering heart healthy foods ).
The gain was larger in the mandatory intervention (62,000 quality-adjusted life-years [QALYs]) vs the current voluntary endorsement label program (8000 QALYs). The interventions were pro-equity with relatively greater health gain for indigenous people (Māori).
USA, Choi et al 2015 
Expansion of the National Salt Reduction Initiative to ensure all restaurants and manufacturers reach agreed upon sodium targets. These cut sodium in 62 categories of packaged, and 25 categories of restaurant, food items.
This expansion “would be expected to avert from 0.9 to 3.0 MIs [myocardial infarctions] (a 1.6–5.4 % reduction) and 0.5 to 2.8 strokes (a 1.1–6.2 % reduction) per 10,000 Americans per year over the next decade.” Most of the benefit came from changes in packaged foods. Also that “even high levels of consumer addition of table salt or substitution among food categories would be unlikely to neutralize this benefit”. The intervention was not found to reduce ethnic inequalities. No cost data were included.
England, Gillespie et al 2015 
Mandatory reductions in all processed foods (10 % and 30 %). Voluntary reformation (24 %) – based on expert panel.
By the year 2025, maximum life-years gained by the mandatory reductions: at 43,900 for the 30 % and 14,800 for the 10 % levels. For voluntary: 14,300 life-years gained. The benefit in reducing health inequalities was greater for the mandatory than the voluntary interventions (when considering absolute differences in life-years).
Such information is important given that one of the approaches recommended by the WHO is food reformulation with “target setting” for food manufacturers . Indeed, 13 European countries have “developed or are in the process of developing national targets for salt reduction, covering between one and 80 food categories” . Moreover, some of these countries have already adopted mandatory targets (as maximal levels) e.g., Belgium, Bulgaria, Finland, Greece, Hungary, Portugal, and The Netherlands [14, 15]. There has also been progress around salt-reduction targets by nations in South America  and for South Africa . Some of the best evidence for the benefit of reducing sodium levels in processed foods comes from the UK where sodium reduction targets, as part of a national sodium reduction strategy, have resulted in reduced sodium intakes at the population level [18–20].
Given this picture, we aimed to build on our previous modeling work  to estimate with uncertainty the health gain and cost-effectiveness of a country achieving the reduction recommended by WHO for dietary sodium intake, and also for the specific food category target components.
Model structure and perspective
The model was a Markov macro-simulation model in TreeAge Pro version 2013, from which we have previously published modeling interventions . The simulated population was a closed cohort of the New Zealand population aged 35 years and older (2.3 million people), modeled from the baseline year (2011). The Markov model has four primary health states, with annual transition rates capturing incidence and case-fatality for coronary heart disease (CHD) and stroke events (see the diagram in an online Technical Report  on the BODE3 website; www.otago.ac.nz/bode3). The simulated population move through these health states until death or age 100 years, with the modeled intervention changing the annual transition probabilities of the population moving into these health states.
In terms of modeling background disease trends we took the same approach as the New Zealand Burden of Disease Study (NZBDS) , and assumed a continued decline in incidence rates for both CHD and stroke of 2.0 % annually, and also a 2.0 % reduction in case-fatality annually i.e., reflecting improved treatment and management. We extended this projection from 2016 (NZBDS end estimate) to the year 2026 and then held the incidence and case-fatality rates constant. Background population mortality was assumed to decline at a somewhat lower rate than for CVD with a 1.75 % annual reduction for non-Māori, and 2.25 % for the indigenous population of Māori (also out to the year 2026), then 0 % per annum decline for both ethnic groupings thereafter (for justification see: [23, 24]).
A health system perspective was used and costs and benefits beyond the health system (e.g., productivity gains from preventing premature deaths of workers) were considered out of scope. However, additional health system costs arising from extra life expectancy in the future attributable to the impact of the modeled interventions were included in the baseline analyses. Costs were calculated in 2011 New Zealand dollars and a 3 % discount rate was applied to costs and future health gain.
All interventions were evaluated against a theoretical “do nothing” comparator as per typical modeling practice . This required us to remove the impact of the existing sodium reduction interventions in place in New Zealand of dietary counselling by dietitians and an endorsement food labeling program run by the Heart Foundation . However, both of these interventions have relatively little impact on sodium intakes, and thus the analysis is fairly similar to a comparison with “current practice”.
These parameters are summarized in the text below with additional details shown in Table A, Table B and Table C in Additional file 1.
Incidence, prevalence and case-fatality
The estimated incidence, prevalence and case-fatality rates of CHD and stroke (ischemic and hemorrhagic) were calculated across all combinations of sex, 5 year age-groups (35–39, 40–44, … 95+ years) and ethnicity (Māori; and non-Māori). Data came from ‘Health Tracker’, which is a collection of linked administrative datasets of publically-funded health system events managed by the Ministry of Health . Health Tracker includes hospitalizations, mortality, cancer registrations, mental health and addiction service use, pharmaceutical and laboratory claims, primary health care enrolment, and outpatient/emergency department visits for the entire New Zealand population with costs attached.
Validation of model parameters and the final model outputs (relative to two official data sources) are detailed in an online Validation Report . This additional work also involved parameter coherence checking using the epidemiological software program DisMod II .
Subsequently, we also conducted a model validation exercise by comparing our TreeAge model with a multi-state life-table model, similar to the one used in a tobacco tax modeling study . For the same sodium reduction intervention of a 22.8 mmol/day reduction in dietary intake (as used in our previous modeling ), the overall QALYs gained were 110,000 in our TreeAge model and 103,000 in the multi-state life-table model (both with 3 % discounting). We regarded this 6 % difference in results as acceptable given the models differed slightly in aspects of model structure and in baseline disease incidence rates and baseline case-fatality rates.
Morbidity and disability weights
Overall morbidity, by sex, age and ethnicity, was quantified in the model using the years of life lived with disability (YLDs) from the NZBDS , divided by the population count to give ‘prevalent’ YLDs. Disease-specific morbidity was assigned in each disease state (e.g., CHD and stroke), as the total comorbidity-adjusted YLDs for that disease divided by the prevalent population. The health status valuation used to calculate these YLDs were disability weights (DW) derived from the Global Burden of Disease study (GBD2010) using pair-wise comparisons from multi-country surveys  (e.g., as opposed to using disutilities from the EuroQol). These DWs are on a scale from 0 (full health) to 1.0 (death) and include uncertainty (for details see the online Technical Report ). The quality-adjusted life-years (QALYs) were then cumulatively tallied for the life-span of the modeled cohort.
The “full target” and component food category targets were based on an evidence-based New Zealand salt reduction “target model”. Specific details of this work are in Table A in Additional file 1 and a thesis available online . In brief, this “target model” involved estimating the sources of sodium in the typical New Zealand adult diet from a combination of market research company data on food purchases (electronically scanned by a consumer panel) and “Nutritrack” data for the brand-specific nutritional composition of packaged foods available in New Zealand supermarkets . Salt consumed at home and in other foods away from the home was estimated from both National Nutrition Survey data , and US data . Reductions in sodium in various food categories were partly informed by the UK Salt Reduction Targets for 2017, which had benefited from extensive consultation with the food industry . The “full target” was a 35 % reduction in dietary salt (from 8.4 g to 5.5 g), to ensure an extra margin of success in meeting the WHO country recommendation of a 30 % relative reduction towards 5 g/day .
Full target and component food category sodium reduction targets modeled
Sodium reduction target details
1) Full target achieved (i.e., 35 % relative reduction to 5.5 g/d of salt) via packaged food target, fast food target and reduced discretionary use
The Intervention 2 target on all packaged foods (36 % reduction in sodium), plus the Intervention 3 target on fast food/restaurant meals (40 % reduction), plus discretionary use reduction (40 % reduction) but no changes to other foods. Overall there was a 35 % reduction.
2) Packaged foods target achieved
The specific targets for all packaged foods – including those packaged foods in this table and others in the full model  (a 36 % reduction in sodium in these foods overall).
3) Fast food and restaurant target achieved
An overall reduction of 40 % in sodium in these foods.
4) Bread target achieveda
Targets ranged from a 12 % reduction in wholemeal bread to a 37 % reduction in “other bread”. The most common target was to reduce to 350 mg sodium per 100 g of bread. A systematic review has indicated that salt can be reduced by approximately 40 % in breads .
5) Processed meats target achieveda
Targets ranged from a 35 % reduction in “cured meats” to a 55 % reduction in “other meat products” (covering all categories except for “raw” and “frozen” meat). A systematic review has indicated that salt can be reduced by approximately 70 % in processed meats .
6) Sauces target achieveda
Targets ranged from a 30 % reduction in marinades to a 63 % reduction in “powdered mixes for meal-based sauces”.
7) Package of Interventions 4 to 6
The combined (fully additive) effect of achieving the targets for bread, processed meats, and sauces collectively (the top three contributors to dietary sodium).
8) Snack food target achieveda
Targets ranged from a 34 % reduction in “extruded snacks” to a 48 % reduction in “potato chips”.
9) All bread and bakery target achieveda
As per Intervention 4 but with all other bakery products added (54 % reduction in “sweet biscuits” and 63 % reduction in “cakes, muffins and pastries”).
10) Cheese target achieveda
Targets ranged from a 27 % reduction in “hard block cheese” to a 42 % reduction in “soft/fresh cheese”.
Costing of intervention scenarios and health system costs
We considered the net cost, which is the intervention costs plus health system costs throughout the lifespan of the modeled cohort (i.e., the results captured additional health costs associated with any extra lifespan generated by the interventions). Specific details for the costing of the interventions are provided in Table C in Additional file 1. For health system costs, the ‘business-as-usual’ ones were determined by strata of sex and age using Health Tracker data, which links cost estimates to all health events. From this dataset we calculated the 2011 costs for the first year of CHD and stroke, and then the average annual cost for the second and subsequent years. Furthermore, given that CVD is a relatively important part of baseline health system costs, we adjusted the baseline health system costs experienced by the “healthy” component of the modeled population, to remove the CVD-attributable cost component (to avoid double-counting).
Of note is that gaps in Health Tracker data exist in specific areas (e.g., some private sector expenditure and the health-related aspects of residential care ) and so we scaled up both the CVD disease costs and the annual health system costs for the non-diseased population. For the disease costs we scaled up Health Tracker costs across all age groups by 1.2, given that 83 % of all health spending in New Zealand is public (i.e., 1/0.83 = 1.2). Finally, costs at older ages were multiplied by 1.1, 1.2, 1.3 for the 65–74, 75–84 and 85+ age groups respectively to capture the estimated missing data of residential ‘disability support services’ care funded through government (‘Vote:Health’) but not yet captured in available data. All costs included those in the last 6 months of life.
For each of the interventions a reduction in dietary sodium intake was linked to a reduction in systolic blood pressure (BP) based on values derived from the regression models developed by Law et al  (see Table A in Additional file 1 for details). A reduction in systolic BP was then linked to a reduced probability of adverse health outcomes (CHD and stroke) as per a meta-analysis of 61 prospective studies by Lewington et al . From this we generated QALYs gained and changes in health costs (from reduced disease burden and increased life expectancy). Analyses were by sex, ethnicity, and age-group.
We reran models (usually for expected values only) for a range of scenarios to assess the impact of components of the interventions and other structural assumptions (e.g., the discount rate: at 0 and 6 %). As an additional scenario analysis for the voluntary interventions, we modeled an effect size that was half of the baseline values to account for plausible non-compliance with the food category targets.
Population level results for the health gain and cost of the 10 sodium reduction interventions (95 % uncertainty intervals) a
Health gain (QALYs for remainder of the cohort’s life)
Health system cost (NZ$; millions) for remainder of the cohort’s life
“Do nothing” comparator b
33.2 million (33.0 to 33.4 million)
162,000 (145,000 to 181,000)
Incremental to “Do nothing
– Mandatory measures achieved
1) Full target
235,000 (176,000 to 298,000)
-1260 (-1710 to 870)
2) Packaged foods target
122,000 (98,200 to 149,000)
-660 (-868 to 480)
3) Fast food & restaurant target
68,700 (55,200 to 83,600)
-370 (-487 to 270)
4) Bread target
8900 (7100 to 10,800)
-45.2 (-61 to 32)
5) Processed meats target
13,400 (10,800 to 16,200)
-70.0 (-94 to 50)
6) Sauces target
20,000 (16,100 to 24,300)
-106 (-141 to 77)
7) Package of Interventions 4 to 6
42,400 (34,200 to 51,500)
-228 (-302 to 167)
8) Snack food target
6100 (5000 to 7400)
-30.3 (-40 to 21)
9) All bread and bakery target
20,400 (16,600 to 24,800)
-108 (-141 to 78)
10) Cheese target
8800 (7100 to 10,600)
-44.6 (-59 to 32)
– Voluntary measures achieved
1) Full target
222,000 (168,000 to 284,000)
-1170 (-1600 to 798)
2) Packaged foods target
115,000 (85,300 to 147,000)
-608 (-827 to 425)
3) Fast food & restaurant target
64,700 (48,000 to 82,200)
-338 (-461 to 236)
4) Bread target
8400 (6200 to 10,600)
-35.7 (-52 to 22)
5) Processed meats target
12,700 (9600 to 16,000)
-58.4 (-82 to 38)
6) Sauces target
18,900 (14,400 to 23,900)
-91.9 (-128 to 61)
7) Package of Interventions 4 to 6
40,100 (30,500 to 50,700)
-205 (-281 to 141)
8) Snack food target
5800 (4400 to 7300)
-22.0 (-34 to 12)
9) All bread and bakery target
19,400 (14,700 to 24,400)
-95.1 (-134 to 63)
10) Cheese target
8300 (6300 to 10,500)
-35.4 (-52 to 22)
Net health gain and costs incremental to “do nothing” by socio-demographic group for selecteda sodium reduction interventions (expressed per adult in 2011, over the remainder of their life with 3 % discounting)
Full target (mandatory)
Packaged foods target (mandatory)
Fast foods & restaurant target (mandatory)
Snacks target (mandatory)
Health gain (QALYs) per adult
Cost per adult (NZ$)
Health gain (QALYs) per adult
Cost per adult (NZ$)
Health gain (QALYs) per adult
Cost per adult (NZ$)
Health gain (QALYs) per adult
Cost per adult (NZ$)
Age < 65 yearsb
Age 65+ yearsb
Costs were strongly and linearly associated with QALYs, as the intervention costs were usually small meaning that avoided future health system costs were vastly more important, and reduced disease incidence co-generates QALY gains and reduced health system costs. All interventions were cost-saving (Table 3), with this being highest for the mandatory approach to the full target at $1260 million saved over the lifetime of the modeled cohort (compared to $1170 million for the full target via the voluntary approach). A cost-effectiveness plane in Fig. 1 shows results, with uncertainty, for a range of the mandatory interventions.
For all interventions, the health gains were greater for mandatory compared with voluntary approaches. The benefit was also greater per capita for men and for Māori e.g., 25 % more than non-Māori for the full target (see examples in Table 4). For all interventions in all socio-demographic groups, the interventions were also cost-saving.
The overall cost results were largely driven by averted disease treatment costs for CVD, followed by the increased health system costs from extra lives lived (as a result of the interventions) (Table D in Additional file 1).
Scenario analyses showed that even with a higher 6 % discount rate, all interventions (and both mandatory and voluntary approaches) still produced net health system cost savings (Table E in Additional file 1). Net cost savings also occurred when we modeled an effect size that was half of the baseline values for the voluntary approach (to account for plausible non-compliance with the targets, Table F in Additional file 1).
Tornado plots demonstrate how uncertainty in input parameters had an impact on the uncertainty in the model’s outputs (Figure A in Additional file 1 for the “packaged foods target” intervention). Uncertainty for costs was particularly driven by the uncertainty in the level of CHD disease cost (especially for men) and the effect size of the BP change for CHD risk.
For QALY gains, the most important drivers of modeled uncertainty were the extent of the sodium reduction (especially in men) and the effect size of the BP change for CHD risk and stroke risk.
Main findings and interpretation
This study adds to the existing modeling-level evidence that interventions for reducing dietary sodium have the potential to generate large health gains and also large cost-savings for a health system. It suggests that there are large differences in the health and cost impact of the different specific targets, along with notable levels of uncertainty. Of the specific components of the full target intervention, it would seem the priority ones for maximizing health gain are the categories of “all packaged foods”, and then “fast foods and restaurant meals” (achieving 52 and 29 % of the health gain of the full target respectively). This pattern is similar to that found in a US modeling study .
Although these interventions based on reformulation are promising, other salt reduction interventions using the same model produce even larger health gain and greater cost savings: a sinking lid on the supply of salt and a salt tax . Indeed, such salt reduction interventions may produce even greater health gains than regular increases in tobacco tax – at least for New Zealand . However, reformulation interventions are particularly important to study because they may be more politically acceptable than other measures.
Mandatory approaches to achieving the targets were estimated to generate more health gain and be more cost-effective than voluntary ones. This pattern has been reported by others (see studies in Table 1 for Australia, England and New Zealand). Nevertheless, such differences may partly reflect various assumptions around intervention phase-in periods and intervention costs.
All interventions modeled were cost-saving and health inequality reducing as they generated greater QALY gains per adult for both the indigenous Māori population and men. This inequality reduction is similar to our previous work , and it reflects higher background CVD rates in Māori so that there is more potential for health gain from reducing blood pressure in Māori (there are minimal differences in sodium intakes between Māori and non-Māori). In contrast, no such pattern of inequality reduction by ethnic group has been reported for a salt-reduction intervention in the USA .
The collective results of this modeling work will probably have a reasonable applicability to other developed countries since high sodium intakes are common and a major risk to health internationally . Nevertheless, the impact on health inequalities may vary between countries depending on population groups, background CVD risk, intake of processed foods, and genetic variation in salt sensitivity . Countries can also differ in the levels of sodium in processed food . Nonetheless, even with diverse food cultures in Europe, many of the countries are targeting similar types of food for salt reduction .
Study strengths and limitations
This study built on previous New Zealand and Australian modeling work to explore a wide range of food category specific salt-reduction interventions. It appears to be only the second such modeling paper to consider such a large range of food categories (after Choi et al ) and also one of the few to use targets based on an evidence-based dietary salt reduction target model or specifically compare voluntary and mandatory approaches. The modeling work also benefited from relatively high quality cost and ethnicity data.
Issues with model structure; and indeed our uncertainty estimates do not capture uncertainty arising from “model structure uncertainty”. For example, this model did not capture potential benefits of salt reduction on preventing stomach cancer  and renal disease . Also, any potential benefits arising from the addition of extra potassium to processed food were not considered (as might be expected as per this systematic review  if food manufacturers replaced some sodium chloride with potassium chloride).
Limitations around input parameters (e.g., particularly relating to the proportion of dietary sodium coming from fast food and restaurant meals and assumptions made in missing purchasing data for the dietary salt reduction target model). There were also limitations with current Health Tracker costs and some epidemiological data (e.g., prevalence of CVD ) and we also did not include uncertainty surrounding the phase-in periods for the interventions.
Unknowns in how the public and industry might respond to achieving the targets were not captured. For example, the food industry might respond by adding flavor compensating ingredients such as more sugar, which could off-set some of the health benefits of sodium reductions (if sugar levels were also not regulated).
Potential research and policy implications
Given this and other past work (Introduction and Table 1), the key research issue for most countries is probably to identify barriers (political and otherwise) to implementing various dietary salt reduction measures. If these barriers are considerable, then policy-makers could start with less ambitious reductions (but ideally still mandatory ones) via maximum sodium limits on various packaged foods. Or they could focus first on high sodium foods that can be considered to be non-essential (e.g., snack foods) or which have other health risks (e.g., the cancer risk from processed meats ). One way to potentially gain public support would be to combine the use of salt reduction targets with improvements in nutrient labeling and conducting mass media campaigns on the health hazard of high sodium diets. Finally, one way that stricter salt reduction targets might be more easily achieved is to encourage the food industry to use potassium salts as substitutes for sodium chloride (as used in Finland ).
Policy-makers who remain skeptical of the scientific basis for dietary sodium reduction and of the results of modeling studies have such choices as waiting for more evidence from experimental studies (e.g., a large trial underway in China ). Or they could focus on broader dietary interventions that may reduce the intake of dietary energy and free sugars as well as sodium (e.g., a Mexico-style “junk food” tax). Also if they wish to just focus on reducing the very high dietary intakes of sodium that virtually all researchers agree are hazardous (above 5000 mg sodium per day as per the Global Burden of Disease 2013 Study ), then they could target products that may particularly contribute to such high intakes (e.g., high sodium sauces).
This work provides modeling-level evidence that achieving reduced sodium intakes via food category targets would generate large health gain and cost savings for the health sector. The categories of “all packaged foods”, then “fast foods and restaurant meals” appear to be the priority categories for achieving the largest health gains. These interventions may also be pro-equity by achieving larger per person benefits for men and indigenous populations.
This study was supported by a grant from the Health Research Council of New Zealand (grant 10/248). The funding source had no role in the design of this study, its execution, analyses, interpretation of the data, and decision to submit results. The authors thank June Atkinson and Giorgi Kvizhinadze for work on the disease costs.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- GBD 2013 Risk Factors Collaborators, Forouzanfar M, Alexander L, Anderson H, Bachman V, Biryukov S, Brauer M, Burnett R, Casey D, Coates M, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323.View ArticlePubMedGoogle Scholar
- Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, Baugh V, Bekedam H, Billo N, Casswell S, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377(9775):1438–47.View ArticlePubMedGoogle Scholar
- WHO: Guideline: Sodium intake for adults and children. Geneva, World Health Organization (WHO). http://www.who.int/nutrition/publications/guidelines/sodium_intake_printversion.pdf. (Accessed 22 Apr 2016.)
- Nghiem N, Blakely T, Cobiac LJ, Pearson AL, Wilson N. Health and economic impacts of eight different dietary salt reduction interventions. PLoS One. 2015;10(4):e0123915.View ArticlePubMedPubMed CentralGoogle Scholar
- Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake and reduced cardiovascular risk. Circulation. 2014;129(9):981–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC. Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Br J Nutr 2015;113(1):1-15. Google Scholar
- Deckers IA, van den Brandt PA, van Engeland M, Soetekouw PM, Baldewijns MM, Goldbohm RA, Schouten LJ. Long-term dietary sodium, potassium and fluid intake; exploring potential novel risk factors for renal cell cancer in the Netherlands Cohort Study on diet and cancer. Br J Cancer. 2014;110(3):797–801.View ArticlePubMedGoogle Scholar
- Edwards DG, Farquhar WB. Vascular effects of dietary salt. Curr Opin Nephrol Hypertens. 2015;24(1):8–13.View ArticlePubMedGoogle Scholar
- Farquhar WB, Edwards DG, Jurkovitz CT, Weintraub WS. Dietary Sodium and Health: More Than Just Blood Pressure. J Am Coll Cardiol. 2015;65(10):1042–50.View ArticlePubMedPubMed CentralGoogle Scholar
- Poggio R, Gutierrez L, Matta MG, Elorriaga N, Irazola V, Rubinstein A. Daily sodium consumption and CVD mortality in the general population: systematic review and meta-analysis of prospective studies. Public Health Nutr. 2015;18(4):695–704.View ArticlePubMedGoogle Scholar
- Wang G, Labarthe D. The cost-effectiveness of interventions designed to reduce sodium intake. J Hypertens. 2011;29(9):1693–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Wang G, Bowman BA. Recent economic evaluations of interventions to prevent cardiovascular disease by reducing sodium intake. Curr Atheroscler Rep. 2013;15(9):349.View ArticlePubMedPubMed CentralGoogle Scholar
- World Health Organization: Creating an enabling environment for population-based salt reduction strategies: report of a joint technical meeting held by WHO and the Food Standards Agency, United Kingdom, July 2010. 2010. http://whqlibdoc.who.int/publications/2010/9789241500777_eng.pdf. (Accessed 22 Apr 2016)
- European Commission: Survey on members states implementation of the EU salt reduction framework: Directorate-General Health and Consumers, 2012. http://ec.europa.eu/health/nutrition_physical_activity/docs/salt_report1_en.pdf. (Accessed 22 Apr 2016).
- Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients. 2014;6(8):3274–87.View ArticlePubMedPubMed CentralGoogle Scholar
- Campbell N, Legowski B, Legetic B, Ferrante D, Nilson E, Campbell C, L’Abbe M. Targets and timelines for reducing salt in processed food in the Americas. J Clin Hypertens. 2014;16(9):619–23.View ArticleGoogle Scholar
- Charlton K, Webster J, Kowal P. To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs. Nutrients. 2014;6(9):3672–95.View ArticlePubMedPubMed CentralGoogle Scholar
- He FJ, Brinsden HC, Macgregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens. 2014;28:345–52.View ArticlePubMedGoogle Scholar
- Brinsden HC, He FJ, Jenner KH, Macgregor GA. Surveys of the salt content in UK bread: progress made and further reductions possible. BMJ Open 2013;3(6):e002936.Google Scholar
- Eyles H, Webster J, Jebb S, Capelin C, Neal B, Ni Mhurchu C. Impact of the UK voluntary sodium reduction targets on the sodium content of processed foods from 2006 to 2011: Analysis of household consumer panel data. Prev Med. 2013;57:555–60.View ArticlePubMedGoogle Scholar
- Nghiem N, Wilson N, Blakely T. Technical Background to the Cardiovascular Disease Model used in the BODE3 Programme. Wellington: Department of Public Health, University of Otago. http://www.otago.ac.nz/wellington/otago070188.pdf; 2014. (Accessed 22 Apr 2016).
- Ministry of Health: Ways and Means: A report on methodology from the New Zealand Burden of Disease, Injury and Risk Study, 2006 - 2016. Wellington: Ministry of Health, 2013. http://www.health.govt.nz/publication/ways-and-means-report-methodology-new-zealand-burden-disease-injury-and-risk-study-2006–2016. (Accessed 22 Apr 2016).
- Woodward A, Blakely T. The Healthy Country? A History of Life and Death in New Zealand. Auckland: Auckland University Press; 2014.Google Scholar
- Blakely T, Foster R, Wilson N, BODE3 Team. Burden of Disease Epidemiology, Equity and Cost-Effectiveness (BODE3) Study Protocol. Version 2.1. Technical Report No.3. Wellington: Department of Public Health, University of Otago, Wellington, December 2012. http://www.otago.ac.nz/wellington/otago042986.pdf. (Accessed 22 Apr 2016).
- Baltussen R, Adam T, Tan-Torres Edejer T, Hutubessy R, Acharya A, et al. Methods for generalized cost-effectiveness analysis. In: Tan-Torres Edejer T, Baltussen R, Adam T, Hutubessy R, Acharya A, et al., editors. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: World Health Organization; 2003.Google Scholar
- Blakely T, Atkinson J, Kvizhinadze G, Nghiem N, McLeod H, Davies A, Wilson N. Updated New Zealand health system cost estimates from health events by sex, age and proximity to death: further improvements in the age of ‘big data’. N Z Med J. 2015;128(1422):13–23.PubMedGoogle Scholar
- Nghiem N, Wilson N, Blakely T. Validation Issues Relating to the Cardiovascular Disease Model Developed in the BODE3 Programme. Wellington: Department of Public Health, University of Otago; 2014. http://www.otago.ac.nz/wellington/otago070189.pdf. (Accessed 22 Apr 2016).
- Barendregt J, Oortmarssen GJ, Vos T, Murray CJL. A generic model for the assessment of disease epidemiology: the computational basis of DisMod II. Popul Health Metr. 2003;1(1):4.View ArticlePubMedPubMed CentralGoogle Scholar
- Blakely T, Cobiac LJ, Cleghorn CL, Pearson AL, van der Deen FS, Kvizhinadze G, Nghiem N, McLeod M, Wilson N. Health, health inequality, and cost impacts of annual increases in tobacco tax: Multistate life table modeling in New Zealand. PLoS Med. 2015;12(7):e1001856.View ArticlePubMedPubMed CentralGoogle Scholar
- Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A, Begum N, Shah R, Karyana M, Kosen S, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2129–43.View ArticlePubMedGoogle Scholar
- Shields E: Salt Reduction in New Zealand. The Development of a New Zealand Salt Reduction Model. Thesis for Master of Health Sciences in Nutrition and Dietetics, The University of Auckland, 2014. https://eshieldsdietitian.wordpress.com/. (Accessed 22 Apr 2016).
- Eyles H, Ni Mhurchu C. Potential for electronic household food purchase data to enhance population nutrition monitoring. N Z Med J. 2014;127(1403):68–71.PubMedGoogle Scholar
- University of Otago and Ministry of Health. A Focus on Nutrition: Key findings of the 2008/09 New Zealand Adult Nutrition Survey. Wellington: Ministry of Health; 2011. http://www.health.govt.nz/publication/focus-nutrition-key-findings-2008-09-nz-adult-nutrition-survey. (Accessed 22 Apr 2016).
- Centers for Disease Control and Prevention. Vital signs: food categories contributing the most to sodium consumption - United States, 2007–2008. MMWR. 2012;61(5):92–8.Google Scholar
- Department of Health: Salt Reduction 2017. United Kingdom, 2014. https://responsibilitydeal.dh.gov.uk/pledges/pledge/?pl=49. (Accessed 22 Apr 2016).
- Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood-pressure? 1. Analysis of observational data among populations. BMJ. 1991;302(6780):811–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–13.View ArticlePubMedGoogle Scholar
- Choi SE, Brandeau ML, Basu S. Expansion of the National Salt Reduction Initiative: A mathematical model of benefits and risks of population-level sodium reduction. Med Decis Making. 2016;36(1):72–85.View ArticlePubMedGoogle Scholar
- Doaei S, Gholamalizadeh M. The association of genetic variations with sensitivity of blood pressure to dietary salt: A narrative literature review. ARYA Atheroscler. 2014;10(3):169–74.PubMedPubMed CentralGoogle Scholar
- Dunford E, Webster J, Woodward M, Czernichow S, Yuan WL, Jenner K, Ni Mhurchu C, Jacobson M, Campbell N, Neal B. The variability of reported salt levels in fast foods across six countries: opportunities for salt reduction. CMAJ. 2012;184(9):1023–8.View ArticlePubMedPubMed CentralGoogle Scholar
- D’Elia L, Rossi G, Ippolito R, Cappuccio FP, Strazzullo P. Habitual salt intake and risk of gastric cancer: a meta-analysis of prospective studies. Clin Nutr. 2012;31(4):489–98.View ArticlePubMedGoogle Scholar
- Smyth A, O’Donnell MJ, Yusuf S, Clase CM, Teo KK, Canavan M, Reddan DN, Mann JF. Sodium intake and renal outcomes: A systematic review. Am J Hypertens. 2014;27:1277–84.View ArticlePubMedGoogle Scholar
- Aburto NJ, Hanson S, Gutierrez H, Hooper L, Elliott P, Cappuccio FP. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ. 2013;346:f1378.View ArticlePubMedPubMed CentralGoogle Scholar
- International Agency for Research on Cancer (World Health Organization): IARC Monographs evaluate consumption of red meat and processed meat. Lyon, France; International Agency for Research on Cancer, 2015.Google Scholar
- He FJ, Jenner KH, Macgregor GA. WASH-world action on salt and health. Kidney Int. 2010;78(8):745–53.View ArticlePubMedGoogle Scholar
- Li N, Yan LL, Niu W, Labarthe D, Feng X, Shi J, Zhang J, Zhang R, Zhang Y, Chu H, et al. A large-scale cluster randomized trial to determine the effects of community-based dietary sodium reduction--the China Rural Health Initiative Sodium Reduction Study. Am Heart J. 2013;166(5):815–22.Google Scholar
- Cobiac LJ, Vos T, Veerman JL. Cost-effectiveness of interventions to reduce dietary salt intake. Heart. 2010;96(23):1920-1925.Google Scholar
- Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM. Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis. Ann Int Med. 2010;152(8):481–487, W170–483.View ArticlePubMedGoogle Scholar
- Rubinstein A, Colantonio L, Bardach A, Caporale J, Marti SG, Kopitowski K et al. Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina. BMC Public Health. 2010;10:627.View ArticlePubMedPubMed CentralGoogle Scholar
- Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F. Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Eff Resour Alloc. 2009;7:10Google Scholar
- Bertram MY, Steyn K, Wentzel-Viljoen E, Tollman S, Hofman KJ. Reducing the sodium content of high-salt foods: effect on cardiovascular disease in South Africa. S Afr Med J. 2012;102(9):743–745.View ArticlePubMedGoogle Scholar
- Cobiac LJ, Magnus A, Lim S, Barendregt JJ, Carter R, Vos T. Which interventions offer best value for money in primary prevention of cardiovascular disease? PLoS One. 2012;7(7):e41842.View ArticlePubMedPubMed CentralGoogle Scholar
- Konfino J, Mekonnen TA, Coxson PG, Ferrante D, Bibbins-Domingo K. Projected impact of a sodium consumption reduction initiative in Argentina: an analysis from the CVD policy model--Argentina. PLoS One. 2013;8(9):e73824.View ArticlePubMedPubMed CentralGoogle Scholar
- Hendriksen MA, Hoogenveen RT, Hoekstra J, Geleijnse JM, Boshuizen HC, van Raaij JM. Potential effect of salt reduction in processed foods on health. Am J Clin Nutr. 2014;99(3):446–453.View ArticlePubMedGoogle Scholar
- Wilson N, Nghiem N, Eyles H, Ni Mhurchu C, Cobiac LJ, Pearson AL et al. Possible impact of the Tick Programme in New Zealand on selected nutrient intakes: Tentative estimates and methodological complexities. N Z Med J. 2014;127(1399):85–88.PubMedGoogle Scholar
- Gillespie DO, Allen K, Guzman-Castillo M, Bandosz P, Moreira P, McGill R et al. The Health Equity and Effectiveness of Policy Options to Reduce Dietary Salt Intake in England: Policy Forecast. PLoS One. 2015;10(7):e0127927.View ArticlePubMedPubMed CentralGoogle Scholar
- Jaenke R, Barzi F, McMahon E, Webster J, Brimblecombe J. Consumer Acceptance of Reformulated Food Products: A Systematic Review and Meta-analysis of Salt-reduced Foods. Crit Rev Food Sci Nutr. 2016:0.Google Scholar