A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries

What is being reported?

A cost-effectiveness analysis to investigate policies that could be used to reduce the consumption of salt in Palestine, Syria, Tunisia and Turkey. This was measured in predicted costs of healthcare saved and life years gained (LYG)

Where did the data come from and what did they do?

The authors used country specific IMPACT CHD models developed as part of the MEDCHAMPs project. These explain past trends in CHD and predict future trends, using standard treatments and major risk factors.

An initial literature review revealed several policies which could be undertaken to decrease salt intake in the population. Health promotion campaign, labelling of packaging, and recipe reformulation were identified. The costs of implementing and monitoring each policy were obtained from the official departments and from interviews with manufacturers of food.

The researchers also performed a literature review to give estimates of the reduction of current salt intake that could be attributed to each policy. The expected blood pressure readings as a result of the change in salt intake, given the policy, were used to give the number of prevented or postponed deaths in ten years. Healthcare costs came from the Ministry of Health in each government. Policies were also explored in combination. 

Why do this?

The burden of coronary heart disease (CHD) is growing quickly in middle income countries and is predicted to have overtaken infectious diseases in all regions bar Subsaharan Africa by 2020. Major CHD risk factors, such as hypertension, high cholesterol and obestity have been increasing as a result of changes in diet and lower levels of physical activity, as well as high rates of tobacco use. The Eastern Mediterannean region is projected to carry the highest burden if current trend continue.

Diets high in salt increase blood pressure which is a contributing factor in CHD mortality. If dietary salt is reduced from 10g to 5g daily, CHD could be reduced by 17% worldwide. Daily salt intake was estimated at 14g for Tunisia, Syria and Palestine and 18g per day in Turkey in 2013.

What were the results?


All policies in all countries gained some life years, however the healthcare cost savings were not always greater than the cost of implementation. In Tunisia, all policies were cost saving apart from health promotion. In Syria and Palestine, the policies involving health promotion and labelling were cost saving. Reformulation of recipes was only cost saving when combined with health promotion and labelling of packaging. In Turkey, all policies were cost saving.

Minimum effectiveness estimates, costs saved (in $) against not implementing policy

When looking at the minimum estimated cost savings, in Tunisia the policies on their own were not cost saving, but combinations of reformulation and health promotion, and reformulation and labelling, as well as all three, were cost saving. In Syria, only labelling was cost saving. In Palestine, health promotion and labelling alone were cost saving, as well as reformulation and health promotion in combination. In Turkey, all policies remained cost saving.

 What was concluded?

"Decreasing dietary salt intake could generate substantial health benefits in terms of life years gained and cost savings."

Salt reduction policies appear to be an effective way of reducing the burden of CHD. In the west, reformulation of processed food to reduce salt has already begun, so the impact of the change in salt level in mass produced imported foods can serve to speed up the process of salt reduction at no extra cost to the home country. Although some policies were not cost saving, they were considered cost effective by the researchers because of the predicted life years gained by implementation.

 Click here to read the paper

Mason H, Azza Shoaibi A, Rula Ghandour R, Martin O'Flaherty M, Simon Capewell S, Rana Khatib R, Samer Jabr S, Belgin Unal B, Kaan Sözmen K, Chokri Arfa C, Aissi W, Romdhane HB, Fouad F. "A Cost Effectiveness Analysis of Salt Reduction Policies to Reduce Coronary Heart Disease in Four Eastern Mediterranean Countries" PLOS ONE 07 January 2014