Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil

PLOS ONE, Jul 2020

Introduction Cardiovascular diseases (CVDs) represent the main cause of death among non-communicable diseases (NCDs) in Brazil, and they have a high economic impact on health systems. Most populations around the world, including Brazilians, consume excessive sodium, which increases blood pressure and the risk of CVDs. Objective To model the estimated deaths and costs associated with CVDs, which are mediated by increased blood pressure attributable to excessive sodium consumption in adults from the perspective of the Brazilian public health system in 2017. Methods We employed two macrosimulation methods, using top-down approaches and based on the same relative risks. The models estimated the mortality and costs-of-illness attributable to excessive sodium intake and mediated by hypertension for adults aged over 30 years in 2017. Direct healthcare cost data (inpatient care, outpatient care and medications) were extracted from the Ministry of Health information systems and official records. Results In 2017, an estimated 46,651 deaths from CVDs could have been prevented if the average sodium consumption had been reduced to 2 g/day in Brazil. Premature deaths related to excessive sodium consumption caused 575,172 Years of Life Lost and US$ 752.7 million in productivity losses to the economy. In the same year, the National Health System’s costs of hospitalizations, outpatient care and medication for hypertension attributable to excessive sodium consumption totaled US$192.1 million. The main causes of death and costs associated with CVDs were coronary heart disease and stroke, followed by hypertensive disease, heart failure and aortic aneurysm. Conclusion Excessive sodium consumption is estimated to account for 15% of deaths by CVDs and to 14% of the inpatient and outpatient costs associated with CVD. It also has high societal costs in terms of premature deaths. CVDs are a leading cause of disease and economic burden on the global, regional and country levels. As a largely preventable and treatable conditions, CVDs require the strengthening of cost-effective policies, supported by evidence, including modeling studies, to reduce the costs relating to illness borne by the Brazilian public health system and society.

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Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil

PLOS ONE RESEARCH ARTICLE Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil Eduardo Augusto Fernandes Nilson ID1*, Adriana Blanco Metlzer2, Marie-Eve Labonté3, Patrı́cia Constante Jaime4 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Global Health and Sustainability, School of Public Health, University of Sao Paulo, Sao Paulo, São Paulo, Brazil, 2 Costa Rican Institute of Research and Training in Nutrition and Health (INCIENSA), San Jose, Costa Rica, 3 Institute of Nutrition and Functional Foods, Laval University, Québec City, Quebec, Canada, 4 Department of Global Health and Sustainability, School of Public Health, University of Sao Paulo, Sao Paulo, São Paulo, Brazil * Abstract OPEN ACCESS Introduction Citation: Nilson EAF, Metlzer AB, Labonté M-E, Jaime PC (2020) Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil. PLoS ONE 15(7): e0235514. https://doi.org/ 10.1371/journal.pone.0235514 Cardiovascular diseases (CVDs) represent the main cause of death among non-communicable diseases (NCDs) in Brazil, and they have a high economic impact on health systems. Most populations around the world, including Brazilians, consume excessive sodium, which increases blood pressure and the risk of CVDs. Editor: Tatsuo Shimosawa, International University of Health and Welfare, School of Medicine, JAPAN Objective Received: February 28, 2020 Accepted: June 16, 2020 Published: July 9, 2020 Copyright: © 2020 Nilson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Computerized raw data files and documentation from the surveys are publicly available from the Brazilian Institute of Geography and Statistics – IBGE (ftp://ftp.ibge.gov. br/PNS/2013/microdados/pns_2013_microdados_ 2017_03_23.zip, https://www.ibge.gov.br/ estatisticas/sociais/populacao/9109-projecao-dapopulacao.html?=&t=downloads) and complete tables on mortality and costs of morbidity are publicly available from the Department of Informatics of the (http://tabnet.datasus.gov.br/cgi/ deftohtm.exe?sim/cnv/obt10uf.def, http://tabnet. To model the estimated deaths and costs associated with CVDs, which are mediated by increased blood pressure attributable to excessive sodium consumption in adults from the perspective of the Brazilian public health system in 2017. Methods We employed two macrosimulation methods, using top-down approaches and based on the same relative risks. The models estimated the mortality and costs-of-illness attributable to excessive sodium intake and mediated by hypertension for adults aged over 30 years in 2017. Direct healthcare cost data (inpatient care, outpatient care and medications) were extracted from the Ministry of Health information systems and official records. Results In 2017, an estimated 46,651 deaths from CVDs could have been prevented if the average sodium consumption had been reduced to 2 g/day in Brazil. Premature deaths related to excessive sodium consumption caused 575,172 Years of Life Lost and US$ 752.7 million in productivity losses to the economy. In the same year, the National Health System’s costs of hospitalizations, outpatient care and medication for hypertension attributable to excessive sodium consumption totaled US$192.1 million. The main causes of death and costs PLOS ONE | https://doi.org/10.1371/journal.pone.0235514 July 9, 2020 1 / 15 PLOS ONE Modelling salt recommendations on cardiovascular disease mortality and costs in Brazil datasus.gov.br/cgi/deftohtm.exe?sih/cnv/niuf.def, http://www2.datasus.gov.br/DATASUS/index.php? area=0901&item=1&acao=22&pad=31655). Details on the modelling inputs are available in the Supplementary Materials. associated with CVDs were coronary heart disease and stroke, followed by hypertensive disease, heart failure and aortic aneurysm. Funding: This article was possible due to an unrestricted research grant from the IDRC (International Research Development Centre of Canada), project #108167, “Scaling Up and Evaluating Salt Reduction Policies and Programs in Latin American Countries". The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results. Excessive sodium consumption is estimated to account for 15% of deaths by CVDs and to 14% of the inpatient and outpatient costs associated with CVD. It also has high societal costs in terms of premature deaths. CVDs are a leading cause of disease and economic burden on the global, regional and country levels. As a largely preventable and treatable conditions, CVDs require the strengthening of cost-effective policies, supported by evidence, including modeling studies, to reduce the costs relating to illness borne by the Brazilian public health system and society. Conclusion Competing interests: The authors have declared that no competing interests exist. Introduction Non-communicable diseases (NCDs) are the main cause of death and disability globally and in Brazil. According to the Global Burden of Disease studies, in 2017, 11 million deaths and 255 million Disability Adjusted Years (DALYs) were attributable to dietary risk factors worldwide. A high intake of sodium is considered the primary diet-related risk factor (being responsible for 3 million deaths and 70 million DALYs), because of its strong association with NCDs, such as cardiovascular diseases (ischemic heart disease, stroke, and hypertension) [1]. Cardiovascular diseases are one of the leading causes of global mortality and morbidity, and they also represent a major economic burden on health care systems in terms of the direct (e.g., medical consultations, hospitalizations, rehabilitation services, and drugs) and indirect (e.g., losses of productivity due to premature mortality and short- or long-term disability) costs associated with mortality and morbidity. The costs of CVDs, as NCDs, are likely to continue to grow due to inadequate diets, an increase in obesity and the aging of societies, so it is very important to address the burden of these diseases in terms of mortality, morbidity and the costs to health systems and society. In addition, economic studies can provide evidence to support CVD prevention programs, which are very cost-effective measures, compared to the costs associated with treating CVD-related conditions [2]. In recent decades, the development of many health and economic modelling methodologies, involving both macro and microsimulations and static and dynamic analysis has improved and supported policy decisions by analyzing the potential impact and cost-effectiveness of health interv (...truncated)


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Eduardo Augusto Fernandes Nilson, Adriana Blanco Metlzer, Marie-Eve Labonté, Patrícia Constante Jaime. Modelling the effect of compliance with WHO salt recommendations on cardiovascular disease mortality and costs in Brazil, PLOS ONE, 2020, Volume 15, Issue 7, DOI: 10.1371/journal.pone.0235514