A systematic review of economic evaluations of population-based sodium reduction interventions.

OBJECTIVE: To summarise evidence describing the cost-effectiveness of population-based interventions targeting sodium reduction. METHODS: A systematic search of published and grey literature databases and websites was conducted using specified key words. Characteristics of identified economic evaluations were recorded, and included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: Twenty studies met the study inclusion criteria and received a full paper review. Fourteen studies were identified as full economic evaluations in that they included both costs and benefits associated with an intervention measured against a comparator. Most studies were modelling exercises based on scenarios for achieving salt reduction and assumed effects on health outcomes. All 14 studies concluded that their specified intervention(s) targeting reductions in population sodium consumption were cost-effective, and in the majority of cases, were cost saving. Just over half the studies (8/14) were assessed as being of 'excellent' reporting quality, five studies fell into the 'very good' quality category and one into the 'good' category. All of the identified evaluations were based on modelling, whereby inputs for all the key parameters including the effect size were either drawn from published datasets, existing literature or based on expert advice. CONCLUSION: Despite a clear increase in evaluations of salt reduction programs in recent years, this review identified relatively few economic evaluations of population salt reduction interventions. None of the studies were based on actual implementation of intervention(s) and the associated collection of new empirical data. The studies universally showed that population-based salt reduction strategies are likely to be cost effective or cost saving. However, given the reliance on modelling, there is a need for the effectiveness of new interventions to be evaluated in the field using strong study designs and parallel economic evaluations.

The effect of prices on nutrition: Comparing the impact of product- and nutrient-specific taxes.

This paper provides an analysis of the role of prices in determining food purchases and nutrition using very detailed transaction-level observations for a large, nationally-representative sample of US consumers over the period 2002-2007. Using product-specific nutritional information, we develop a new method of partitioning the product space into relevant nutritional clusters that define a set of nutritionally-bundled goods, which parsimoniously characterize consumer choice sets. We then estimate a large utility-derived demand system over this joint product-nutrient space that allows us to calculate price and expenditure elasticities. Using our structural demand estimates, we simulate the role of product taxes on soda, sugar-sweetened beverages, packaged meals, and snacks, and nutrient taxes on fat, salt, and sugar. We find that a 20% nutrient tax has a significantly larger impact on nutrition than an equivalent product tax, due to the fact that these are broader-based taxes. However, the costs of these taxes in terms of consumer utility are only about 70 cents per household per day. A sugar tax in particular is a powerful tool to induce healthier nutritive bundles among consumers.

Salty or sweet? Nutritional quality, consumption, and cost of snacks served in afterschool programs.

BACKGROUND: Snacks served in afterschool programs (ASPs, 3-6 pm) represent an important opportunity to promote healthy eating. ASP policies suggest a fruit/vegetable is served daily, while sugar-sweetened foods/beverages and artificially flavored snacks are eliminated. Limited information exists on the types of snacks served in ASPs, if snacks meet existing nutrition policies, whether children eat the snacks, and their cost. METHODS: Direct observation of snacks served and consumed was collected in 20 ASPs serving over 1700 elementary age children. The number of days that snacks were served/week was evaluated for compliance with nutrition policies. Costs of snacks were collected via receipts. RESULTS: Programs served desserts and artificially flavored salty snacks on 2.7 and 2.1 days/week. Fruits and vegetables were served 0.6 and 0.1 days/week, respectively. Sugar-sweetened beverages were served 1.8 days/week. Of the children (N = 383) observed, 75% to 100% consumed the snack served, with 95% and 100% of served fruits/vegetables consumed. No ASP served fruit/vegetables daily, 18 served sugar-sweetened foods, 16 served artificially flavored snacks, and 14 served sugar-sweetened beverages. Desserts and salty snacks cost $0.27-$0.32/snack vs $0.38-$0.40/snack for vegetables/fruits. CONCLUSIONS: The quality of snacks failed to meet nutrition policies and consists of predominately high-sugar and artificially flavored options. Strategies to improve snack offerings in ASPs while addressing price barriers are required.

The relation of potassium and sodium intakes to diet cost among U.S. adults.

The 2010 Dietary Guidelines recommended that Americans increase potassium and decrease sodium intakes to reduce the burden of hypertension. One reason why so few Americans meet the recommended potassium or sodium goals may be perceived or actual food costs. This study explored the monetary costs associated with potassium and sodium intakes using national food prices and a representative sample of US adults. Dietary intake data from the 2001-2002 National Health and Nutrition Examination Survey were merged with a national food prices database. In a population of 4744 adults, the association between the energy-adjusted sodium and potassium intakes, and the sodium-to-potassium ratio (Na:K) and energy-adjusted diet cost was evaluated. Diets that were more potassium-rich or had lower Na:K ratios were associated with higher diet costs, while sodium intakes were not related to cost. The difference in diet cost between extreme quintiles of potassium intakes was $1.49 (95% confidence interval: 1.29, 1.69). A food-level analysis showed that beans, potatoes, coffee, milk, bananas, citrus juices and carrots are frequently consumed and low-cost sources of potassium. Based on existing dietary data and current American eating habits, a potassium-dense diet was associated with higher diet costs, while sodium was not. Price interventions may be an effective approach to improve potassium intakes and reduce the Na:K ratio of the diet. The present methods helped identify some alternative low-cost foods that were effective in increasing potassium intakes. The identification and promotion of lower-cost foods to help individuals meet targeted dietary recommendations could accompany future dietary guidelines.

Effect of Flammulina velutipes on spent-hen breast meat tenderization.

An experiment was carried out to investigate the effects of powdered vegetable dip sauces to improve the tenderness of spent-hen breast meat. Our overall purpose was to find lower-priced materials for the tenderization of spent-hen breast meat. The spent-hen breast meat was dipped into vegetable powder for 24 h at 4°C, and then the samples were analyzed. In the results for vegetable-powder treated samples, those treated with papain and pineapple had higher (P ≤ 0.05) myofibrillar fragmentation indices compared with those of the other samples. The kiwi-, pineapple-, and Flammulina velutipes-powder (winter mushroom) treated samples had new peptides of about 32 kDa and degradation to 30 kDa. Also, the Flammulina velutipes-powder treated samples showed new peptides of 15 kDa. These data imply that Flammulina velutipes is superior for common use than papain or pineapple for the tenderization of spent-hen meat.

Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis.

BACKGROUND: Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake. OBJECTIVE: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax. DESIGN: A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke. DATA SOURCES: Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data. TARGET POPULATION: U.S. adults aged 40 to 85 years. TIME HORIZON: Lifetime. PERSPECTIVE: Societal. OUTCOME MEASURES: Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted. RESULTS OF BASE-CASE ANALYSIS: Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period. RESULTS OF SENSITIVITY ANALYSIS: Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake. LIMITATION: Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict. CONCLUSION: Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses. PRIMARY FUNDING SOURCE: Department of Veterans Affairs, Stanford University, and National Science Foundation.

Potential societal savings from reduced sodium consumption in the U.S. adult population.

PURPOSE: Policies that address the food environment at the population level may help prevent chronic disease, but their value to society is still uncertain. Dietary sodium is linked to increased prevalence of hypertension, a primary risk factor for cardiovascular and renal diseases. This study calculates the potential societal savings of reducing hypertension and related cardiovascular disease via a reduction in population-level sodium intake. On average, U.S. adults consume almost twice the recommended maximum of dietary sodium, most of it from processed foods. DESIGN: This study modeled sodium-reduction scenarios by using a cross-sectional simulation approach. The model used population-level data on blood pressure, antihypertensive medication use, and sodium intake from the National Health and Nutrition Examination Survey (1999-2004). This data was then combined with parameters from the literature on sodium effects, disease outcomes, costs, and quality of life to yield model outcomes. MEASURES: This study calculated the following outcome measures: hypertension prevalence, direct health care costs, and quality-adjusted life years for noninstitutionalized U.S. adults. ANALYSIS: The simulation was conducted with STATA 9.2 and Microsoft Excel. Survey weights were used to calculate population averages. RESULTS: Reducing average population sodium intake to 2300 mg per day, the recommended maximum for adults, may reduce cases of hypertension by 11 million, save $18 billion health care dollars, and gain 312,000 QALYs that are worth $32 billion annually. Greater reductions in population sodium consumption bring even greater savings to society. CONCLUSIONS: Large benefits to society may result from efforts to lower sodium consumption on a population level by modest amounts over time. Although savings in direct health care costs are likely to be quite high, they could easily be matched or exceeded by the value of quality-of-life improvements.

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

PURPOSE: Model the potential national health benefits and medical savings from reduced daily intake of calories, sodium, and saturated fat among the U.S. adult population. DESIGN: Simulation based on secondary data analysis; quantitative research. Measures include the prevalence of overweight/obesity, uncontrolled hypertension, elevated cholesterol, and related chronic conditions under various hypothetical dietary changes. SETTING: United States. SUBJECTS: Two hundred twenty-four million adults. MEASURES: Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports. ANALYSIS: The simulation model predicts disease prevalence and medical expenditures under hypothetical dietary change scenarios. RESULTS: We estimate that permanent 100-kcal reductions in daily intake would eliminate approximately 71.2 million cases of overweight/obesity and save $58 billion annually. Long-term sodium intake reductions of 400 mg/d in those with uncontrolled hypertension would eliminate about 1.5 million cases, saving $2.3 billion annually. Decreasing 5 g/d of saturated fat intake in those with elevated cholesterol would eliminate 3.9 million cases, saving $2.0 billion annually. CONCLUSIONS: Modest to aggressive changes in diet can improve health and reduce annual national medical expenditures by $60 billion to $120 billion. One use of the model is to estimate the impact of dietary change related to setting public health priorities for dietary guidance. The findings here argue that emphasis on reduction in caloric intake should be the highest priority.

Predicted national productivity implications of calorie and sodium reductions in the American diet.

PURPOSE: To model the potential long-term national productivity benefits from reduced daily intake of calories and sodium. DESIGN: Simulation based on secondary data analysis; quantitative research. Measures include absenteeism, presenteeism, disability, and premature mortality under various hypothetical dietary changes. SETTING: United States. SUBJECTS: Two hundred twenty-five million adults. MEASURES: Findings come from a Nutrition Impact Model that combines information from national surveys, peer-reviewed studies, and government reports. ANALYSIS: We compare current estimates of national productivity loss associated with overweight, obesity, and hypertension to estimates for hypothetical scenarios in which national prevalence of these risk factors is lower. Using the simulation model, we illustrate how modest dietary change can achieve lower national prevalence of excess weight and hypertension. RESULTS: We estimate that permanent 100-kcal reductions in daily intake among the overweight/obese would eliminate approximately 71.2 million cases of overweight/obesity. In the long term, this could increase national productivity by $45.7 billion annually. Long-term sodium reductions of 400 mg in those with uncontrolled hypertension would eliminate about 1.5 million cases, potentially increasing productivity by $2.5 billion annually. More aggressive diet changes of 500 kcal and 1100 mg of sodium reductions yield potential productivity benefits of $133.3 and $5.8 billion, respectively. CONCLUSIONS: The potential long-term benefit of reduced calories and sodium, combining medical cost savings with productivity increases, ranges from $108.5 billion for moderate reductions to $255.6 billion for aggressive reductions. These findings help inform public health policy and the business case for improving diet. (AmJ Health Promot 2009;23[6]:423-430.)

Monetary cost of self-reported diet in relation to biomarker-based estimates of nutrient intake in young Japanese women.

OBJECTIVE: All previous studies on monetary diet cost have examined the relationship of monetary cost of self-reported diet to self-reported, rather than biomarker-based, estimates of dietary intake. The present cross-sectional study examined the association between monetary costs of self-reported diet and biomarker-based estimates of nutrient intake. DESIGN: Monetary diet cost (Japanese yen/1000 kJ) was calculated based on dietary intake information from a self-administered, comprehensive diet history questionnaire using retail food prices. Biomarker-based estimates of nutrient intake (percentage of energy for protein and mg/1000 kJ for K and Na) were estimated based on 24 h urinary excretion and estimated energy expenditure. SETTING: A total of fifteen universities and colleges in Japan. SUBJECTS: A total of 1046 female Japanese dietetic students aged 18-22 years. RESULTS: Total monetary diet cost showed a significant positive association with biomarker-based estimates of protein, K and Na. Vegetables and fish were not only the main contributors to total monetary diet cost (16.4 % and 15.5 %, respectively) but also were relatively strongly correlated with total monetary diet cost (Pearson's correlation coefficient: 0.70 and 0.68, respectively). Monetary cost of vegetables was significantly positively associated with all three nutrients, while that of fish showed a significant and positive association only with protein. CONCLUSIONS: Total monetary cost of self-reported diet was positively associated with biomarker-based estimates of protein, K and Na intake in young Japanese women, and appeared mainly to be explained by the monetary costs of vegetables and fish.

Profitability and acceptability of fat- and sodium-modified hot entrees in a worksite cafeteria.

OBJECTIVES: To compare the acceptability of fat- and sodium-modified entrees before and after implementation of a marketing program and to determine the effect offering and marketing these healthful entrees had on total cafeteria and entree sales in a worksite cafeteria. DESIGN: The research was conducted in five phases, including sales data collection, acceptance testing of unmodified hot entrees, acceptance testing of modified entrees, and implementation of a marketing campaign for promoting low-fat, sodium-controlled food selections. SETTING: The Kansas Farm Bureau and Affiliated Services (KFB) employee cafeteria. SUBJECTS: KFB employees who ate lunch in the employee cafeteria and were willing to participate in the study. MAIN OUTCOME MEASURES: Sales data (percent of customers purchasing a modified entree and sales of modified entree as a percent of total sales); nutrient analysis data (energy, grams of total fat, percent of energy from fat, milligrams of cholesterol, and milligrams of sodium); and acceptability data (11 characteristics were measured using a seven-point hedonic scale). STATISTICAL ANALYSIS PERFORMED: General linear model analysis of variance was used to compare sales data from phases 1 to 5 and to compare acceptability data from phases 2 to 4. RESULTS: No significant differences in sales data were observed during the 7-month study. No significant changes in overall acceptability were found for any entree. However, customers tended to rate overall acceptability higher when entrees were marketed as lower in fat and sodium. APPLICATIONS/CONCLUSIONS: Customers in worksite cafeterias may be more willing to tolerate changes in flavor attributes when modified entrees are marketed as "healthful" and nutrition information is available.