Estimated health and economic effects of different salt reduction strategies on cardiovascular disease in Brazil: a microsimulation analysis

Excessive salt consumption is an important risk factor for cardiovascular diseases (CVD), especially through increased blood pressure. In Brazil, the average salt intake is almost twice the international recommendations, and current population-level salt-reduction policies include only voluntary maximum sodium targets for packaged foods and awareness strategies. This study aims to quantify the potential health and economic impacts of additional salt-reduction strategies in Brazil from 2019 to 2038. We used a previously validated microsimulation of a close-to-reality synthetic population (IMPACT NCD-BR ) to estimate CVD events (cases and deaths) prevented or postponed and the corresponding cost savings from 2019 to 2038, stratified by age and sex. The policy scenarios modelled were 1) maintaining the voluntary limits for maximum sodium content in packaged foods; 2) enforcing mandatory lower limits for maximum sodium content in packaged foods; 3) mandatory front-of-pack labelling warnings for excessive sodium in foods, in addition to scenario 1; and 4) universal use of 10% potassium table salt, in addition to scenario 1. Model inputs were informed by nationally representative health and food consumption surveys and high-quality meta-analyses. The cost analysis incorporated the costs of CVD treatment to the National Health System and the costs of informal care. The study found that from 2019 to 2038, maintaining the current voluntary targets could prevent or postpone some 280,000 CVD case-years (95% UI: 140,000 to 490,000) and 5,700 CVD deaths (95% UI: 2,500 to 9,500). Mandatory limits on the salt content of packaged foods could prevent or postpone 590,000 CVD case-years (95% UI: 260,000 to 1,000,000) and 12,000 CVD deaths (95% UI: 5,900 to 19,000). During the same period, mandatory front-of-pack labelling warnings, in addition to the current voluntary targets, could prevent or postpone approximately 420,000 CVD case-years (95% UI: 190,000 to 740,000) and some 8,400 CVD deaths (3,300 to 14,000). The replacement of regular table salt with 10% potassium salt, in addition to the current voluntary targets, could prevent or postpone approximately 870,000 CVD case-years (400,000 to 1,400,000) and 63,000 CVD deaths (31,000 to 96,000). The estimated cost savings related to CVD treatment from implementing the four scenarios were approximately Int$ 0.8 billion (Int$ 0.4b to 1.4b), Int$ 1.7b (Int$ 0.7b to 3.0b), Int$ 1.2b (Int$ 0.5b to 2.2b), and Int$ 2.2b (Int$ 1.1b to 3.9b), respectively. The current Brazilian voluntary sodium targets for packaged foods may yield modest health and economic impacts compared with other strategies. Our analysis suggests that stricter regulatory salt targets for the food industry, mandatory front-of-pack warning labels for excessive sodium in foods, and universal use of low-sodium table salt could substantially improve the health and economic benefits of salt reduction for the Brazilian people and help achieve the World Health Organization goals for salt intake more quickly and more effectively.