Recent Economic Evaluations of Interventions to Prevent Cardiovascular Disease by Reducing Sodium Intake


Excess intake of sodium, a common problem worldwide, is associated with hypertension and cardiovascular disease (CVD), and hypertension is a major risk factor for CVD. Population-wide efforts to reduce sodium intake have been identified as a promising strategy for preventing hypertension and CVD, and such initiatives are currently recommended by a variety of scientific and public health organizations. By reviewing the literature published from January 2011 to March 2013, we summarized recent economic analyses of interventions to reduce sodium intake. The evidence, derived from estimates of resultant blood pressure decreases and thus decreases in the incidence of CVD events, supports population-wide interventions for reducing sodium intake. Both lowering the salt content in manufactured foods and conducting mass media campaigns at the national level are estimated to be cost-effective in preventing CVD. Although better data on the cost of interventions are needed for rigorous economic evaluations, population-wide sodium intake reduction can be a promising approach for containing the growing health and economic burden associated with hypertension and its sequelae.

This is a preview of subscription content, access via your institution.

Fig. 1


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

    Google Scholar 

  2. 2.

    Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3:e442.

    PubMed  Article  Google Scholar 

  3. 3.

    Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics─2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-245.

    Google Scholar 

  4. 4.

    Leal J, Luengo-Fernández R, Gray A, Petersen S, Rayner M. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J. 2006;27:1610–9.

    PubMed  Article  Google Scholar 

  5. 5.

    Luengo-Fernández R, Leal J, Gray A, Petersen S, Rayner M. Cost of cardiovascular diseases in the United Kingdom. Heart. 2006;92:1384–9.

    PubMed  Article  Google Scholar 

  6. 6.

    World Health Organization. The world health report 2002 - reducing risks, promoting healthy life. Geneva: WHO; 2002. Accessed 23 May 2013.

    Google Scholar 

  7. 7.

    Pan American Health Organization-World Health Organization. Cardiovascular disease prevention through dietary salt reduction. Washington: PAHO-WHO; 2011. Accessed 5 Apr 2013.

    Google Scholar 

  8. 8.

    United Nations. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. January 24, 2012., Accessed 4 Apr 2013.

  9. 9.

    Morrison AC, Ness RB. Sodium intake and cardiovascular disease. Annu Rev Public Health. 2011;32:71–90.

    PubMed  Article  Google Scholar 

  10. 10.

    He FJ, MacGregor GA. Salt reduction lowers cardiovascular risk: meta-analysis of outcome trials. Lancet. 2011;378:380–2.

    PubMed  Article  Google Scholar 

  11. 11.

    Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ. 2007;334:885–8.

    PubMed  Article  Google Scholar 

  12. 12.

    Graudal NA, Hubeck-Graudal T, Jürgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens. 2012;25:1–15.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    O’Donnell MJ, Yusuf S, Mente A, et al. Urinary sodium and potassium excretion and risk of cardiovascular events. JAMA. 2011;306:2229–38.

    PubMed  Article  Google Scholar 

  14. 14.

    He FJ, Campbell NR, MacGregor GA. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev Panam Salud Publica. 2012;32:293–300.

    PubMed  Article  Google Scholar 

  15. 15.

    Strazzullo P, D’Elia L, Kandala NB, Cappuccio FP. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 2009;339:b4567.

    PubMed  Article  Google Scholar 

  16. 16.

    Coxson PG, Cook NR, Joffres M, et al. Mortality benefits from US population-wide reduction in sodium consumption: projections from 3 modeling approaches. Hypertension. 2013;61:564–70.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    D’Elia L, Barba G, Cappuccio FP, Strazzullo P. Potassium intake, stroke, and cardiovascular disease: a meta-analysis of prospective studies. J Am Coll Cardiol. 2011;57:1210–9.

    PubMed  Article  Google Scholar 

  18. 18.

    Appel LJ, Frohlich ED, Hall JE, et al. The importance of population-wide sodium reduction as a means to prevent cardiovascular disease and stroke: a call to action from the American Heart Association. Circulation. 2011;123:1138–43.

    PubMed  Article  Google Scholar 

  19. 19.

    Stolarz-Skrzypek K, Kuznetsova T, Thijs L, et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA. 2011;305:1777–85.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012;126:2880–9.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Tomonari T, Fukuda M, Miura T, et al. Is salt intake an independent risk factor of stroke mortality? Demographic analysis by regions in Japan. J Am Soc Hypertens. 2011;5:456–62.

    PubMed  Article  Google Scholar 

  22. 22.

    Gardener H, Rundek T, Wright CB, Elkind MS, Sacco RL. Dietary sodium and risk of stroke in the Northern Manhattan study. Stroke. 2012;43:1200–5.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    • Alderman MH, Cohen HW. Dietary sodium intake and cardiovascular mortality controversy resolved? AJH. 2012. doi:10.1038/ajh.2012.52. Although population-wide efforts to reduce sodium intake are promising for preventing hypertension and CVD, this study warned that robust evidence does not support universal reduction of sodium intake. For individuals whose diet falls outside the “safe” range of sodium intake, there is no evidence that reducing sodium intake will lead to better health outcomes..

    Google Scholar 

  24. 24.

    Institute of Medicine. Sodium intake in population: assessment of evidence. Washington: IOM; 2013. Accessed 22 May 2013.

    Google Scholar 

  25. 25.

    National Health Service National Institute for Health and Clinical Excellence. Prevention of cardiovascular disease at population level. NICE public health guidance 25. 2010. Accessed 16 Apr 2013.

  26. 26.

    World Health Organization. Reducing salt intake in populations: report of a WHO forum and technical meeting. Geneva: WHO; 2007.

    Google Scholar 

  27. 27.

    Establishing Guidelines for the Nutrition of Vulnerable Groups (with special reference to the poor). 1969 Conference on Food, Nutrition, and Health. p. 37–100. Accessed 16 Apr 2013.

  28. 28.

    Institute of Medicine. Strategies to reduce sodium intake in the United States. Washington: IOM; 2010. Accessed 30 Mar 2013.

    Google Scholar 

  29. 29.

    Sodium Working Group. Sodium reduction strategy for Canada. Ottawa: Health Canada; 2010. Accessed 30 Mar 2013.

    Google Scholar 

  30. 30.

    Dalziel K, Segal L, Mortimer D. Review of Australia health economic evaluation─245 interventions: what can we say about cost-effectiveness? Cost Eff Resour Alloc. 2008;6:9.

    PubMed  Article  Google Scholar 

  31. 31.

    Schwappach DLB, Boluarte TA, Suhrcke M. The economics of primary prevention of cardiovascular disease─a systematic review of economic evaluations. Cost Eff Resour Alloc. 2007;5:5.

    PubMed  Article  Google Scholar 

  32. 32.

    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;7:10.

    PubMed  Article  Google Scholar 

  33. 33.

    Centers for Disease Control and Prevention . Cost analysis. Accessed 6 Apr 2013.

  34. 34.

    Kind P, Lafata JE, Matuszewski K, Raisch D. The use of QALYs in clinical and patient decision-making: issues and prospects. Value Health. 2009;12 Suppl 1:S27–30.

    PubMed  Article  Google Scholar 

  35. 35.

    Ackerman F. Pricing the priceless: cost-benefit analysis of environmental protection. Univ Penna Law Rev. 2001;150(5)., Accessed 6 Apr 2013.

  36. 36.

    •• Gase LN, Kuo T, Dunet D, Schmidt SM, Simon PA, Fielding JE. Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the county of Los Angeles. Am J Public Health. 2011;101:1501–7. Although this study only focused on a local policy at a county level, the approaches in estimating the health impact as well as the costs of implementation can be applied to other settings. It provided an empirical framework of policy evaluation by estimating both the health impact and the cost of implementation. This is a good step toward developing practical intervention programs..

    PubMed  Article  Google Scholar 

  37. 37.

    Barton P, Andronis L, Briggs A, McPherson K, Capewell S. Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ. 2011;28:343. d4044.

    Google Scholar 

  38. 38.

    Martikainen JA, Soini EJ, Laaksonen DE, Niskanen L. Health economic consequences of reducing salt intake and replacing saturated fat with polyunsaturated fat in the adult Finnish population: estimates based on the FINRISK and FINDIET studies. Eur J Clin Nutr. 2011;65:1148–55.

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Ha DA, Chisholm D. Cost-effectiveness analysis of interventions to prevent cardiovascular disease in Vietnam. Health Policy Plan. 2011;26:210–22.

    PubMed  Article  Google Scholar 

  40. 40.

    •• 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:e41842. This study evaluated various interventions including lifestyle, pharmaceutical, and population-wide interventions over the lifetime of Australian adults in one complex model. The authors proved that the Australian government must enforce moderate salt limits in some processed foods for large and immediate improvement in the health of the population..

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Ferrante D, Konfino J, Mejía R, et al. The cost-utility ratio of reducing salt intake and its impact on the incidence of cardiovascular disease in Argentina [in Spanish]. Rev Panam Salud Publica. 2012;32:274–80.

    PubMed  Article  Google Scholar 

  42. 42.

    Wang G, Labarthe D. The cost-effectiveness of interventions designed to reduce sodium intake. J Hypertens. 2011;29:1693–9.

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Heidenreich PA, Trogdon JG, Khavjou OA. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123:933–44.

    PubMed  Article  Google Scholar 

  44. 44.

    • Appel LJ, Angel SY, Cobb LK, et al. Population-wide sodium reduction: the bumpy road from evidence to policy. Ann Epidemiol. 2012;22:417–25. This study emphasized that cost-effectiveness modeling clearly has a valuable role in policy-making. The results of the economic evaluation can be used to prioritize public health interventions such as population-wide salt intake reduction. Furthermore, the authors offered a number of lessons learned in translating epidemiologic and other scientific findings into policy..

    PubMed  Article  Google Scholar 

  45. 45.

    Mirambeau AM, Wang G, Ruggles L, Dunet DO. A cost analysis of a community health worker program in rural Vermont. J Community Health. 2013. doi:10.1007/s10900-013-9713-x.

  46. 46.

    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 Intern Med. 2010;152:481–7.

    PubMed  Article  Google Scholar 

  47. 47.

    Bibbins-Domingo K, Chertow GM, Coxson PG, et al. Projected effect of dietary salt reduction on future cardiovascular disease. N Engl J Med. 2012;362:590–9.

    Article  Google Scholar 

  48. 48.

    Palar K, Sturm R. Potential societal savings from reduced sodium consumption in the U.S. adult population. Am J Health Promot. 2009;24:49–57.

    PubMed  Article  Google Scholar 

  49. 49.

    Dall TM, Fulgoni 3rd VL, Zhang Y, et al. Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductiuons in the American diet. Am J Health Promot. 2009;23:412–22.

    PubMed  Article  Google Scholar 

  50. 50.

    Dall TM, Fulgoni 3rd VL, Zhang Y, et al. Predicted national productivity implications of calorie and sodium reductions in the American diet. Am J Health Promot. 2009;23:423–30.

    PubMed  Article  Google Scholar 

  51. 51.

    Asaria P, Chisholm D, Mathers C, et al. Chronic disease prevention: health benefits and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370:2044–53.

    PubMed  Article  Google Scholar 

  52. 52.

    Murray CJ, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet. 2003;361:717–25.

    PubMed  Article  Google Scholar 

Download references

Conflict of Interest

Guijing Wang declares no conflict of interest.

Barbara A. Bowman declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information



Corresponding author

Correspondence to Guijing Wang.

Additional information

This article is part of the Topical Collection on Nutrition

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention (CDC).

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Wang, G., Bowman, B.A. Recent Economic Evaluations of Interventions to Prevent Cardiovascular Disease by Reducing Sodium Intake. Curr Atheroscler Rep 15, 349 (2013).

Download citation


  • Salt intake
  • Sodium
  • Cardiovascular disease
  • Costs
  • Hypertension
  • Interventions