Original Article
Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease
N Engl J Med 2010; 362:590-599February 18, 2010
- Abstract
Background
The U.S. diet is high in salt, with the majority coming from processed foods. Reducing dietary salt is a potentially important target for the improvement of public health.
Methods
We used the Coronary Heart Disease (CHD) Policy Model to quantify the benefits of potentially achievable, population-wide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). We estimated the rates and costs of cardiovascular disease in subgroups defined by age, sex, and race; compared the effects of salt reduction with those of other interventions intended to reduce the risk of cardiovascular disease; and determined the cost-effectiveness of salt reduction as compared with the treatment of hypertension with medications.
Results
Reducing dietary salt by 3 g per day is projected to reduce the annual number of new cases of CHD by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and to reduce the annual number of deaths from any cause by 44,000 to 92,000. All segments of the population would benefit, with blacks benefiting proportionately more, women benefiting particularly from stroke reduction, older adults from reductions in CHD events, and younger adults from lower mortality rates. The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels. A regulatory intervention designed to achieve a reduction in salt intake of 3 g per day would save 194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health care costs annually. Such an intervention would be cost-saving even if only a modest reduction of 1 g per day were achieved gradually between 2010 and 2019 and would be more cost-effective than using medications to lower blood pressure in all persons with hypertension.
Conclusions
Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.
Media in This Article
Figure 1
Projected Annual Reductions in Cardiovascular Events Given a Dietary Salt Reduction of 3 g per Day in Black Men, Black Women, Nonblack Men, and Nonblack Women, According to Age Group.Table 1
Estimated Changes in Systolic Blood Pressure Associated with Reductions in Dietary Salt.Article Activity
- Article
The U.S. diet is high in salt. The Departments of Agriculture and Health and Human Services recommend daily intake of less than 5.8 g of salt (2300 mg of sodium), with a lower target of 3.7 g of salt per day for most adults (persons over 40 years of age, blacks, and persons with hypertension).1 Despite these guidelines, during the period from 2005 through 2006, the average man in the United States is estimated to have consumed 10.4 g of salt per day and the average woman 7.3 g per day — amounts that exceed those in preceding years.2
Reducing dietary salt lowers blood pressure and the risk of cardiovascular disease.3,4 Accomplishing this reduction is challenging, however, in part because 75 to 80% of the salt in the U.S. diet comes from processed foods, not from salt added during food preparation or consumption.5,6 Many countries, including Japan, the United Kingdom, Finland, and Portugal, have reduced population-wide salt intake through a combination of regulations on the salt content in processed foods, labeling of processed and prepared foods, public education, and collaboration with the food industry.7 To explore the potential impact of a modest reduction in dietary salt on population health, we used the Coronary Heart Disease (CHD) Policy Model, a computer simulation of heart disease in U.S. adults 35 to 84 years old, and an extension of the model that is used to assess stroke. We estimated the effects in different segments of the U.S. population, compared these projections with the health benefits expected from a range of other public health and clinical interventions aimed at reducing cardiovascular disease, and analyzed the relative cost-effectiveness of salt reduction as compared with treatment of hypertension with medication.
Methods
Structure of the Model
The CHD Policy Model is a computer-simulation, state-transition (Markov cohort) model of the incidence and prevalence of CHD and of the mortality and costs associated with CHD in U.S. residents 35 years of age or older. The model has been used to describe trends in CHD and the effects of interventions intended to reduce the risk of CHD.8,9 (For an overview of the model, see the Supplementary Appendix, available with the full text of this article at NEJM.org.) The model has three submodels: demographic–epidemiologic, bridge, and disease-history. The demographic–epidemiologic submodel predicts the incidence of CHD and the rates of death due to causes other than CHD among persons without a history of CHD. The risk of CHD is categorized according to age, sex, and the following six factors: systolic blood pressure, use or nonuse of antihypertensive medications, smoking status, level of high-density lipoprotein (HDL) cholesterol, level of low-density lipoprotein (LDL) cholesterol, and presence or absence of diabetes mellitus. For persons in whom CHD develops, the bridge submodel characterizes the initial CHD event and its sequelae for 30 days. The disease-history submodel then predicts the rate of subsequent CHD events and rates of death from CHD and of deaths not related to CHD among simulated subjects with CHD, with each category stratified according to age, sex, and history of events. The data in the CHD Policy Model are derived from national data sets and calibrated to national event-rate estimates.
In addition to using the standard CHD Policy Model of the entire U.S. population, we created race-specific versions of the model for the black and nonblack populations. We derived the race-specific distribution of risk factors for CHD from the National Health and Nutrition Examination Survey. Beta coefficients derived from the Framingham Heart Study and the Framingham Offspring Study were applied to all three population groups, but the overall age-specific incidence rates of CHD were specific to each population.10 The average incidence rates for the black and nonblack subpopulations were validated with national data.11 In sensitivity analyses we also examined beta coefficients specific to the black population.12 We did not assign a coefficient to use of antihypertensive medications; rather, we used systolic blood pressure or treatment with antihypertensive medications to define the population of persons with hypertension, who might have a greater response to a reduction in dietary salt. Finally, we extended the model to estimate the incidence of stroke using beta coefficients derived from the Framingham Heart Study and the Framingham Offspring Study and published rates on the incidence of stroke.13,14
Modeling Approach and Underlying Assumptions
We assumed that the effect of salt reduction on blood pressure reduction was linear over the range of 0 to 3 g per day.15 We used a lower estimate for the effect of salt reduction on systolic blood pressure on the basis of the findings of a large meta-analysis3,16 and used a higher estimate for this effect on the basis of data from clinical trials.17,18 We modeled an accentuated response to salt reduction among blacks, persons with hypertension, and persons 65 years of age or older (Table 1Table 1
Estimated Changes in Systolic Blood Pressure Associated with Reductions in Dietary Salt.).17,19-22 We compared the effects of a salt-restricted diet on numbers of CHD events with the effects of other interventions aimed at reducing cardiovascular risk by modeling a 50% reduction in smoking and environmental tobacco exposure,23 a 5% reduction in body-mass index among obese adults,8 treatment of persons at low or intermediate risk with statins in accordance with the guidelines in the Adult Treatment Panel III of the National Cholesterol Education Program,9 and treatment of hypertension as described in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT; ClinicalTrials.gov number, NCT00000542).24,25 We conducted simulations for the entire U.S. population and for black and nonblack subgroups and estimated annual reductions in the incidence of CHD, new and recurrent myocardial infarctions, the incidence of stroke, and death from any cause as a result of reductions in dietary salt for the entire population and for subgroups defined according to age, sex, and race. We projected annual cost savings in health care and annual gains in quality-adjusted life years (QALYs) that would result from an intervention to reduce salt for the entire U.S. population and for Medicare enrollees, on the basis of the World Health Organization estimate that the cost of such a national effort would be $1 per person annually.26 We made the same projections for population-wide treatment of hypertension with antihypertensive medications.25 We also report the cumulative costs and effectiveness for a gradual introduction of the intervention over the decade from 2010 through 2019.
Sensitivity Analyses
We used Monte Carlo simulations to estimate the uncertainty of our projections for both the high and low estimates of the effects of salt reduction on systolic blood pressure. Beta coefficients for the association of systolic blood pressure, LDL and HDL cholesterol, and diabetes with both CHD events and deaths not associated with CHD were assumed to have a normal probability distribution, with standard errors derived from the fitted regression. We generated covariance matrixes for each of these beta coefficients. On the basis of the evidence of minimal correlation between factors, we assumed that the effects were independent. For each simulation, we report the mean (±SE) for 1000 simulations. We conducted sensitivity analyses in which we varied the effect of salt reduction on changes in cardiovascular risk on the basis of estimates suggesting that the risk of cardiovascular disease associated with blood pressures lowered by means of salt reduction or medication is not as low as the risk associated with similar, naturally occurring blood pressures.27,28
Results
A population-wide reduction in dietary salt of 3 g per day (1200 mg of sodium per day) is projected to reduce the annual number of new cases of CHD by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and to reduce the annual number of deaths from any cause by 44,000 to 92,000. Since the relationship between reductions in salt and the projected declines in event rates is linear over the range examined, even a more modest reduction of 1 g of salt per day is projected to result in large declines in annual rates of cardiovascular events and deaths (with new cases of CHD declining by 20,000 to 40,000, new and recurrent cases of myocardial infarction by 18,000 to 35,000, new cases of stroke by 11,000 to 23,000, and deaths from any cause by 15,000 to 32,000).
All adult age groups, both sexes, and blacks and nonblacks would be expected to benefit from reductions in salt intake (Figure 1Figure 1
Projected Annual Reductions in Cardiovascular Events Given a Dietary Salt Reduction of 3 g per Day in Black Men, Black Women, Nonblack Men, and Nonblack Women, According to Age Group.). The anticipated relative benefits among blacks would be greater than those among nonblacks across all age groups and both sexes. The projected reductions in stroke would be greater among women than among men, with rates decreasing by 9 to 15% among black women and by 5 to 9% among nonblack women. All age groups would be expected to benefit, with middle-aged and older populations projected to have larger relative reductions in the incidence of CHD and in rates of new and recurrent myocardial infarction and stroke. A large relative reduction in mortality is projected for young and middle-aged adults, with mortality rates among blacks between 35 and 64 years of age reduced by 7 to 11% and those among nonblacks in this age range reduced by 3 to 6%.Sensitivity Analyses
If a lower blood pressure achieved through reduced salt intake is not as advantageous as the same blood pressure without such intervention, the expected health benefit of salt reduction will be decreased (Table 2Table 2
Projected Estimates of Annual Reductions in Rates of Cardiovascular Disease with a Dietary Salt Reduction of 3 g per Day, in the Main Simulation and According to Various Assumptions about Differential Salt Sensitivity in the Sensitivity Analyses.). If persons 65 years of age or older have the same degree of salt sensitivity as those younger than 65 years of age, the total estimated benefits of salt reduction would also be somewhat decreased. If blacks have no greater salt sensitivity than nonblacks, the magnitude of the anticipated effects on blacks will be reduced, but there will still be greater reductions in cardiovascular events and deaths among blacks because they have a higher prevalence of hypertension.Comparison with Other Interventions
In a projection assuming a reduction in dietary salt of 3 g per day calculated using the high estimate for the effects of salt reduction on systolic blood pressure, the expected reductions in cardiovascular events would be similar in magnitude to or greater than those projected for interventions targeting tobacco, obesity, primary prevention with statins, and pharmacologic treatment of hypertension, based on simulations for the same time frame and overall population (Table 3Table 3
Projected Estimates of Comparative Effect of Various Population Interventions on Annual Reductions in Cardiovascular Events.). For example, a reduction in dietary salt of 3 g per day would have approximately the same effect on rates of CHD events as a 50% reduction in tobacco use, a 5% reduction in body-mass index among obese adults, or the use of statins to treat persons at low or intermediate risk for CHD events. Salt reduction would have a much greater benefit with respect to stroke prevention than these other interventions. A population-wide reduction of salt intake of 3 g per day is expected to result in the same reduction in death rates as the use of medical treatment to control hypertension in all persons with the condition.Cost-Effectiveness
A national effort to decrease salt consumption by 3 g per day would result in an estimated annual gain of 194,000 to 392,000 QALYs and estimated savings of $10 billion to $24 billion in health care costs. Even if salt targets were achieved gradually over the years 2010 through 2019 (Table 4Table 4
Projected Estimates of the Cost and Effectiveness of Salt Reduction and Hypertension Treatment Annually and Cumulatively, 2010–2019.) and a reduction in dietary salt of only 1 g were achieved only by the end of the decade, such an intervention is expected to result in cost savings. A salt-reduction strategy is projected to compare favorably with the provision of antihypertensive therapy for all persons with hypertension — a strategy that would result in more QALYs gained but at a cost of $6,000 to $26,000 for each additional QALY. Even if the federal government were to bear the entire cost of a regulatory program designed to reduce salt consumption, the government would still be expected to realize cost savings for Medicare, saving $6 to $12 in health care expenditures for each dollar spent on the regulatory program. The strategy of providing antihypertensive medications for all persons with hypertension would still be cost-effective if it were added to a successful program of population-wide dietary salt reduction, but the number of persons requiring treatment with such medications would be markedly reduced; the number of women with hypertension would be reduced by 16 to 24%, and the number of men by 22 to 34%, with a savings of $3 billion to $6 billion annually in the cost of treating hypertension.Discussion
Despite evidence linking salt intake to hypertension and cardiovascular disease, dietary salt intake in the U.S. is on the rise. This worsening trend has led to calls for population-wide interventions to reduce salt in the U.S. diet29 — interventions already adopted in other countries.7 Our findings provide evidence to support these calls for action. Our postulated dietary reduction of 3 g of salt per day, which is within the range targeted by other developed countries, is projected to benefit the entire U.S. population and yield substantial reductions in morbidity, mortality, and health care costs. The population-wide benefits of salt reduction are similar in magnitude to the benefits that would accrue from other public health and clinical interventions and would reduce costs even if only a more modest reduction of 1 g of salt per day were achieved gradually over time.
Changes in behavior are notoriously difficult to achieve, and attempts to lower dietary salt intake on an individual basis have largely proved to be ineffective.5 Nevertheless, cholesterol levels in the U.S. population fell before the widespread use of cholesterol-lowering medications, and smoking rates have fallen substantially as the result of a combination of regulatory, public health, and individual approaches to smoking cessation. The large and growing burden of hypertension, despite improved medical therapies,30 and increased awareness that dietary salt reduction can help prevent and treat hypertension reinforce the urgent need for dietary change.
There is a considerable body of literature linking higher salt intake with higher blood pressure and increased cardiovascular risk,16,31 and randomized trials have shown that a diet that is lower in salt reduces both blood pressure17,32 and cardiovascular risk.31 Despite concerns about the accurate assessment of salt intake, the difficulty of adhering to a low-salt diet, and the theoretical increase in the risks associated with diets that are very low in salt, several large meta-analyses and reports from the Institute of Medicine3,5,16,27,34 have concluded that reducing dietary salt would lower blood pressure and reduce cardiovascular risk. Professional societies, including the American Medical Association, the American Heart Association, the American Society of Hypertension, and the World Health Organization, have endorsed population-wide efforts to reduce salt intake.
The results of our study are similar to those of other analyses35,36 and extend the findings of these analyses in important ways. We incorporated updated information on distributions of the prevalence of cardiovascular risk factors, particularly hypertension, in the entire U.S. population and in the black and nonblack subpopulations. We considered current levels of hypertension treatment, treatment and control of other cardiovascular risk factors, and competing and ongoing risks among persons in whom death was averted. Our expectations concerning the cardiovascular benefits of salt reduction are similar to those anticipated for established public health targets such as reducing tobacco use, obesity, and levels of LDL cholesterol. Targeted interventions have very large per-person effects, but their benefits are restricted to the smaller numbers of affected persons who are at increased risk. Lowering salt in the U.S. diet would result in small but measurable reductions in blood pressure across the entire U.S. population, thereby reducing rates of cardiovascular disease among all adults at risk.
A national regulatory effort to lower dietary salt intake would be cost-saving even if only a modest salt reduction were achieved after a decade. If a population-wide approach to lowering salt intake were sponsored by the federal government, the savings in expenditures for Medicare, the major federally sponsored health care program, would be greater than the cost of the regulatory intervention itself, even without the incremental benefits for younger persons not covered by Medicare. Some costs, such as those borne by the food industry in reformulating processed foods, are not considered in these analyses. However, as salt intake is reduced, people appear to prefer food with less salt,15 a phenomenon that is probably related to the accommodation of taste receptors over the course of weeks to months.37 In the United Kingdom, a population-wide reduction in dietary salt of 10% was achieved in 4 years38 without a reduction in sales of the food products included in the initial effort and without consumer complaints about taste. The magnitude of the health benefit suggests that salt should be a regulatory target of the Food and Drug Administration, which currently designates salt as a food additive that is “generally regarded as safe.”29
We projected that similar levels of salt reduction may be of proportionately greater benefit to certain subpopulations. Blacks have high rates of hypertension and cardiovascular diseases that contribute to racial disparities in mortality39; the benefits of a diet lower in salt could narrow these disparities. Similarly, women would have a proportionately greater benefit than men because women have a higher lifetime risk of stroke.11 Young and middle-aged adults could benefit because of the relative importance of blood-pressure elevations in younger adults without other major risk factors for cardiovascular disease. Blood-pressure elevations in young adulthood increase the likelihood that atherosclerosis9 and other illnesses will develop by middle age,40 yet younger adults with hypertension are less likely to receive treatment for it.41 The benefits of salt reduction may be even greater than we have projected if hypertension is completely prevented or its onset delayed by lowering salt intake even earlier, during childhood and adolescence.42
Projections such as ours are limited by any uncertainty concerning the data entered into the model. We modeled the effects of salt reduction on blood pressure in accordance with published data and assumed that the health benefits of salt reduction were mediated through these blood-pressure reductions. We did not account fully for possible effects of salt reduction that are unrelated to control of blood pressure — for example, potential improvements in outcomes for the increasing numbers of patients with heart failure or prevention of other serious conditions, such as end-stage renal disease. Our estimates of the differential effects of salt reduction according to age and race were extrapolated from clinical-trial data, and there is uncertainty about these effects on the total population; however, sensitivity analyses suggest that our primary findings are not dependent on variations in these assumptions. We modeled only the linear effects of reduced salt intake on reductions in blood pressure. It has been suggested that these effects may be nonlinear,17 with greater reductions in blood pressure at lower levels of salt intake; such an assumption would result in larger reductions in cardiovascular disease than we present here.
Even with these limitations, our simulations suggest that modest reductions in dietary salt would yield substantial health benefits across the U.S. population of adults by lowering rates of cardiovascular events and death and reducing medical costs. Our findings underscore the need for an urgent call to action that will make it possible to achieve these readily attainable cardiovascular benefits.
The Framingham Heart Study (FHS) and Framingham Offspring Study (FOS) are conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with FHS and FOS investigators. This article was prepared with the use of a limited-access data set obtained by the NHLBI and does not necessarily reflect the opinions or views of the FHS, the FOS, or the NHLBI.
Supported in part by a grant-in-aid from the American Heart Association Western States Affiliate (09GRNT2060096) and an intramural pilot grant from the University of California, San Francisco Clinical and Translational Sciences Institute (NIH–NCRR UCSF-CTSI UL1 RR024131).
No potential conflict of interest relevant to this article was reported.
This article (10.1056/NEJMoa0907355) was published on January 20, 2010, at NEJM.org.
We thank Tekeshe Mekonnen, M.S., for her invaluable help in the preparation of the text and figures, and David Fairley, Ph.D., who developed the Monte Carlo simulation routine used in the study.
Source Information
From the Departments of Medicine (K.B.-D., P.G.C., M.J.P.), Epidemiology and Biostatistics (K.B.-D., M.J.P.), and Clinical Pharmacy, School of Pharmacy (J.M.L.), University of California, San Francisco (UCSF); and the Division of General Internal Medicine and the Center for Vulnerable Populations at San Francisco General Hospital, UCSF (K.B.-D., P.G.C.) — all in San Francisco; the Department of Medicine, Stanford University, Palo Alto, CA (G.M.C.); and the Department of Medicine, College of Physicians and Surgeons, Columbia University, New York (A.M., L.G.).
Address reprint requests to Dr. Bibbins-Domingo at the University of California, San Francisco, Box 1364 UCSF-SFGH, San Francisco, CA 94143-1364.
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