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BMJ. 2017 Jan 10;356:i6699. doi: 10.1136/bmj.i6699.

Cost effectiveness of a government supported policy strategy to decrease sodium intake: global analysis across 183 nations.

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Stanford University, Stanford, CA, USA, and Institute for Fiscal Studies, London, UK.
Harvard TH Chan School of Public Health, Boston, MA, USA.
Tufts Friedman School of Nutrition Science & Policy, 150 Harrison Ave, Boston, MA 02111, USA.
Cambridge Institute of Public Health, Cambridge, UK.
Tufts Friedman School of Nutrition Science & Policy, 150 Harrison Ave, Boston, MA 02111, USA



 To quantify the cost effectiveness of a government policy combining targeted industry agreements and public education to reduce sodium intake in 183 countries worldwide.


 Global modeling study.


 183 countries.


 Full adult population in each country.


 A "soft regulation" national policy that combines targeted industry agreements, government monitoring, and public education to reduce population sodium intake, modeled on the recent successful UK program. To account for heterogeneity in efficacy across countries, a range of scenarios were evaluated, including 10%, 30%, 0.5 g/day, and 1.5 g/day sodium reductions achieved over 10 years. We characterized global sodium intakes, blood pressure levels, effects of sodium on blood pressure and of blood pressure on cardiovascular disease, and cardiovascular disease rates in 2010, each by age and sex, in 183 countries. Country specific costs of a sodium reduction policy were estimated using the World Health Organization Noncommunicable Disease Costing Tool. Country specific impacts on mortality and disability adjusted life years (DALYs) were modeled using comparative risk assessment. We only evaluated program costs, without incorporating potential healthcare savings from prevented events, to provide conservative estimates of cost effectiveness MAIN OUTCOME MEASURE:  Cost effectiveness ratio, evaluated as purchasing power parity adjusted international dollars (equivalent to the country specific purchasing power of US$) per DALY saved over 10 years.


 Worldwide, a 10% reduction in sodium consumption over 10 years within each country was projected to avert approximately 5.8 million DALYs/year related to cardiovascular diseases, at a population weighted mean cost of I$1.13 per capita over the 10 year intervention. The population weighted mean cost effectiveness ratio was approximately I$204/DALY. Across nine world regions, estimated cost effectiveness of sodium reduction was best in South Asia (I$116/DALY); across the world's 30 most populous countries, best in Uzbekistan (I$26.08/DALY) and Myanmar (I$33.30/DALY). Cost effectiveness was lowest in Australia/New Zealand (I$880/DALY, or 0.02×gross domestic product (GDP) per capita), although still substantially better than standard thresholds for cost effective (<3.0×GDP per capita) or highly cost effective (<1.0×GDP per capita) interventions. Most (96.0%) of the world's adult population lived in countries in which this intervention had a cost effectiveness ratio <0.1×GDP per capita, and 99.6% in countries with a cost effectiveness ratio <1.0×GDP per capita.


 A government "soft regulation" strategy combining targeted industry agreements and public education to reduce dietary sodium is projected to be highly cost effective worldwide, even without accounting for potential healthcare savings.

[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at and declare: financial support from the National Institutes of Health for the submitted work. DM reports ad hoc honorariums or consulting fees from Boston Heart Diagnostics, Haas Avocado Board, Astra Zeneca, GOED, DSM, and Life Sciences Research Organization, none of which were related to topics of dietary sodium. The other authors report no financial relationships with any organizations that might have an interest in the submitted work in the previous three years.

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