Background: Sodium, saturated fat, and sugar intake in Bangladesh is rising, primarily driven by increasing consumption of packaged foods high in these nutrients. A front-of-package nutrient warning label (FoPL) policy is being proposed by the national government to protect against rising rates of diet-related chronic disease. The government is seeking to develop evidence-based limits for sodium, sugar, and saturated fat to support this policy. Objective: To compare the proportion of packaged products that would receive FoPL when three nutrient profile models (NPM) are applied: the Brazil NPM and Chile NPM, based on product weight, and World Health Organization (WHO) NPM (modified from the Pan American Health Organization (PAHO) NPM), based on calories. All three NPMs divide liquids from solids but do not vary across food categories. Methods: Packaged foods and beverages in the Mintel Global New Products Database eligible for a FoPL and displaying information necessary to calculate nutrient content were evaluated. NPM limits were applied to each product. The proportions of products that would display FoPL for each nutrient under each NPM were calculated overall, for foods and beverages separately, and by product category. Results: The display of nutrient values varied across food categories. Among eligible food products, 15% lacked information on sodium content, 25-28% on saturated fat, and 21-26% on sugar (Figure 1). Among the three NPMs used, the Brazil NPM consistently captured fewer eligible products while the WHO NPM captured the most (Figure 2). A “high in sugar” FoPL would be applied to 92% of carbonated soft drinks using the WHO NPM, compared to 74% (Chile NPM) and 70% (Brazil NPM) (Figure 3). 58% of snacks would receive a “high in salt” FoPL (WHO NPM) compared to 50% (Chile NPM), and 29% (Brazil NPM) (Figure 3). Conclusions: The WHO NPM identifies the highest percentage of packaged foods and beverages in Bangladesh high in sodium, saturated fat, and sugar. Because it is grounded in WHO population nutrient intake goals for preventing diet-related chronic disease, it provides a health-protective basis for a FoPL system. This model ensures that the FoPL framework aligns with global public health standards and supports healthier food environments. Irrespective of NPM model used, stronger regulatory enforcement and compliance with nutrient disclosures on labels is needed for comprehensive product classification and effective FoPL policy implementation.

BACKGROUND:Fiscal food policies can improve diets and reduce the burden of diet-related diseases. We aimed to model the effects of various health-promoting food taxes and subsidies in Australia on health, economics, and equity. METHODS:In this modelling study, the modelled scenarios included a 20% tax on unhealthy foods (ie, sugar-sweetened beverages, confectionery, snack foods, biscuits, pastries, ice cream, and processed meat), a 20% subsidy for fruits and vegetables, and a 20% tax on unhealthy foods earmarked to subsidise fruits and vegetables. We used a food demand system and nationally representative dietary intake data from the National Nutrition and Physical Activity Survey to estimate changes in energy, sodium, fruit, and vegetable intake for each policy across 5-year age-sex-socioeconomic status groups. These changes were input into a multiple-cohort proportional multistate lifetable model to estimate premature deaths averted, gains in health-adjusted life-years (HALYs), and health-care cost savings over the lifetime of the 2019 Australian adult population. Analyses were stratified by food category and socioeconomic quintile. FINDINGS:We estimated that a 20% tax on unhealthy foods could avert 212 000 (95% uncertainty interval 196 000-229 000) premature deaths, generate 1370 000 (1270 000-1480 000) HALYs, lower health-care costs by AU$14·9 billion (4·6-27·5), and promote health equity. The estimated HALYs gained could be approximately 7 times greater than by taxing sugar-sweetened beverages alone. Conversely, a 20% subsidy for fruits and vegetables could avert 44 000 (36 000-52 000) premature deaths and generate 203 000 (155 000-249 000) HALYs, but might not lead to meaningful changes in health-care costs. Furthermore, earmarking the 20% tax to fund subsidies for fruits and vegetables could offset some of the financial burden of the tax. INTERPRETATION:Fiscal food policies could be powerful levers to promote health and equity in Australia and should be considered by policy makers. FUNDING:Australian Research Training Program.

Introduction: Consumption of packaged foods and beverages high in sodium, sugar, and saturated fat is increasing in Ethiopia. The Ethiopian government is considering a comprehensive policy package including front-of-pack labeling (FoPL), and restrictions on marketing and procurement to discourage purchase of products exceeding nutrient thresholds. The potential dietary and health impact of this policy is unknown. Objectives: To estimate the dietary and health impacts of implementing the policy package in Ethiopia. Methods: We applied a comparative risk-assessment model to simulate the impact of these policies among adults (≥20 years). Sales data from Euromonitor Passport Database were used as intake proxies, linked with sodium and sugar content from Mintel Global New Products Database. Historic trends were used to project future consumption, and policy-effect on nutrient sales were derived from a real-world evaluation of a similar policy package. Reductions in sodium and sugar intake were used to estimate changes in blood pressure and body-mass index using data from clinical trials, and then converted into averted deaths and disability-adjusted life years (DALYs) using data from global databases and a national survey. Outcomes were estimated for 2025 and 2040 under two packaged food consumption scenarios: current trends (low) and 10% annual growth observed in other middle-income countries (high). Results: Without the policy package, sodium intake from packaged foods is projected to rise from 98 (95% uncertainty interval: 77-119) mg/day (2025) to 125 (96-157) mg/day (low) or 406 (319-500) mg/day (high) by 2040, and sugar from 6.1 (5.7-6.6) g/day to 7.6 (7.0-8.1) g/day (low) or 25.7 (24.1-27.3) g/day (high) ( Figure 1 ). Without policy action, these increases could raise noncommunicable disease (NCD) burden, especially from cardiovascular diseases ( Figure 2 ). Immediate implementation of the policy package could reduce sodium intake by 23% (19–27%) and sugar by 27% (25–29%), averting 384 (253–556) deaths and 5,145 (3,739–6,930) DALYs. Projected benefits substantially increase for both low- and high-trends by 2040 ( Figure 3 ). Conclusions: A policy package including FoPL plus marketing and procurement restrictions, could yield immediate, meaningful health gains in Ethiopia. By 2040, under either current trends or 10% annual growth in packaged-food consumption, these policies could attenuate the projected rise in NCDs driven by sodium and sugar in packaged foods.

ABSTRACT Objective To estimate the benefit and risk of replacing regular salt with potassium-enriched salt. Design Comparative risk assessment modelling. Setting Worldwide Participants Adult populations aged 25 and above. Intervention (1) worldwide replacement of all salt (discretionary salt used for seasoning or cooking in the home, and non-discretionary salt used in processed and restaurant foods); (2) worldwide replacement of just discretionary salt; (3) worldwide replacement of just non-discretionary salt; (4) replacement of discretionary salt just for people with diagnosed hypertension; and (5) replacement of discretionary salt just for people with treated hypertension. Main outcome measures For scenarios 1-3, we estimated benefits including deaths, new cases and disability-adjusted-life-years (DALYs) from cardiovascular disease and chronic kidney disease (CKD), from blood pressure-lowering as well as harms (CVD deaths) caused by hyperkalaemia among people with CKD stages G3-G5. Results Replacement of all salt worldwide could prevent 2.96 (95% uncertainty interval 2.81-3.12) million deaths, 10.17 (9.59-10.70) million new cases of disease and 69.43 (65.61-72.92) million disability-adjusted life years (DALYs) each year. These figures represent 14.6%, 13.1% and 16.5% of the annual global disease burden attributable to CVD and CKD. Replacement of all discretionary salt (1.85, 1.74-1.97 million deaths) would have a greater impact on mortality than replacement of all non-discretionary salt (1.56, 1.46-1.67 million deaths). In people with CKD Stage G3-G5, there would be a net benefit - replacement of all salt would prevent 0.75 (0.71-0.80) million deaths but might cause 0.10 (0.09-0.11) million deaths from hyperkalaemia. Discretionary salt replacement only among diagnosed or treated hypertensives would prevent 0.59 (0.55-0.63) million and 0.48 (0.45-0.52) million deaths, respectively. Conclusion Switching regular salt to potassium-enriched salt appears to offer large potential for health gains under diverse scenarios, including for people with CKD. Funding This work did not receive specific funding. What is already known on this topic - Excess dietary sodium and low dietary potassium intake both cause high blood pressure, which causes a significant burden of cardiovascular disease (CVD) and chronic kidney disease (CKD). - Efforts to cut dietary sodium intake as a strategy to control blood pressure have mostly been unsuccessful, with no country expected to meet the World Health Organisation (WHO) 2025 goal of reducing sodium intake by 30%. - Switching regular salt to potassium-enriched salt has shown clear protection against CVD and causes minimal change in taste and has low cost to scale up, but concerns remain about the potential of causing deaths due to hyperkalaemia among people with advanced chronic kidney disease. What this study adds - The study modelled five different possible approaches to the implementation of potassium-enriched salt that will suit a range of different circumstances, including countries with different levels of discretionary versus non-discretionary salt intake. - The study indicates switching to potassium-enriched salt can prevent very large numbers of CVD and CKD events worldwide, while the potential for causing harm in people with CKD is small in comparison. - There was also net benefit in analyses restricted to just people with CKD, where benefits of blood pressure lowering outweigh potential harms from hyperkalaemia.

IntroductionPopulation-wide dietary sodium reduction is a global priority and a highly cost-effective strategy to lower blood pressure and reduce cardiovascular disease risk. In response, the Nigerian government launched the National Multi-sectoral Action Plan (NMSAP) in 2019, recommending evidence-based policy actions including limiting sodium in processed foods, restricting food advertising especially for children, promoting public awareness, integrating nutrition education in schools, and front-of-package labeling. We conducted a qualitative study to examine progress, barriers, and facilitators in implementing these policy actions 3 years post-launch.MethodsBetween March and September 2024, we conducted 47 key informant interviews and 5 focus group discussions with 22 participants from sectors relevant to sodium reduction, including government, education, food manufacturing and retail, civil society, non-governmental organizations and consumers. Guided by the Integrated Theoretical Framework, we identified determinants influencing policy implementation. Three coders independently coded the data, which were thematically analyzed.ResultsPolicy characteristics that facilitated implementation included emerging nutrient profiling and dietary surveillance systems and ongoing nutrition education; however, limited baseline data, the absence of nationally endorsed front-of-pack labeling frameworks, and unreliable labeling impeded progress. Within inter-organizational relationships, challenges in coordination, governance, and cross-sector communication emerged as overarching barriers to implementation. Implementing agency capacity was constrained by inconsistent enforcement, limited funding, workforce turnover, low awareness of national sodium policies, and resistance from food manufacturers. Regarding attributes and responses of those affected by the policy, strong support for educating children as agents of household change facilitated school-based nutrition education, although entrenched cultural norms around salt use, financial constraints, and limited public knowledge of the health risks of excessive salt consumption hindered broader behavior change. Finally, within the policy context and external environment, the existing use of local herbs and traditional potassium-rich flavorings was identified as a promising opportunity to promote lower-sodium diets.ConclusionThese findings offer critical insights for enhancing implementation, sustainability, and scale-up of evidence-informed policy actions in Nigeria and in other low- and middle-income countries.Clinical trial registrationTrial Registration: NCT04765865.

Background: To massively scale up efforts to diagnose and treat hypertension, different screening strategies have been proposed (population-wide screening campaigns and healthcare facility-based “opportunistic” screening). However, no studies have compared their impact on cardiovascular disease (CVD) prevention in low-resource settings. Objective: To compare hypertension treatment coverage, CVD events, and CVD deaths in Bangladesh from three different screening strategies. Methods: We developed a discrete-time microsimulation model populated with data from the 2018 Bangladesh WHO STEPS survey. Over 10 years, hypertension diagnosis and treatment, CVD events (strokes and ischemic heart disease), and deaths were estimated for a model population (100,000 adults without hypertension diagnosis or CVD history) under 3 scenarios: (1) current practice of limited opportunistic screening in public healthcare facilities (20% of patients screened); (2) extended opportunistic screening in public healthcare facilities (80% of patients screened); and (3) one-time population-wide screening targeting 80% population coverage over 5 years. In (1) and (2), patients visiting public healthcare facilities (30% of population) could be screened multiple times over the 10 years. Ten-year CVD risk was calculated using WHO CVD prediction models recalibrated with country-specific Global Burden of Disease data. Results: Under current practice, 22,129 adults (out of N=100,000) could be screened over 10 years and 2,002 would start treatment ( Figure, Panels A and B ); in this scenario, 12,117 CVD events and 1,548 deaths would occur. In the extended opportunistic screening scenario, 62,680 adults would be screened and 6,222 would initiate treatment. With population-wide screening, 79,482 would be screened, and treatment would begin in 3,171 adults. Compared to current practice ( Panels C and D ), extended opportunistic screening and population-wide screening could prevent 65 and 46 more CVD events, and 33 and 22 CVD deaths per 100,000 over 10 years, respectively. Among adults aged ≥40 years (40% of the total population), the estimated impact on CVD burden was doubled (e.g., 65-70 averted CVD deaths per 100,000). Conclusion: Despite the intuitive appeal of population-wide screening, the most effective screening strategy to increase screening yield and prevent CVD events in Bangladesh and likely other low-resource settings is extended opportunistic screening in public health care facilities.

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Background The Ethiopian government is considering implementation of a front-of-package label policy to address the rising prevalence and burden of diet-related, non-communicable disease. The objective of this study was to determine the most effective labels to discourage purchase of less healthy packaged foods in Ethiopia. Methods This study was a randomized controlled trial with four arms (no label and three labels) among adults in Addis Ababa, Ethiopia (n = 1200). The primary outcome was mean intent to purchase on a 7-point Likert scale across four products. A secondary outcome was the proportion of participants correctly identifying excess sugar or sodium. Results The mean intent to purchase score among participants randomized to the Nutrient Warning Labels arm was 4.37 (95% CI: 4.16, 4.59), which was significantly lower (p ≤ 0.003) than no label, Multiple Traffic Light Label, or Nutri-Score Label arms. 62% of participants in the Nutrient Warning Labels arm correctly identified that either sugar or sodium was in excess across all four products, which was significantly higher than other study arms. Participants reported that Nutrient Warning Labels and the Multiple Traffic Light Label aided in making purchasing decisions, drew attention, were trustworthy, and were easy to understand. Participants were significantly more worried about children consuming food and drink displaying Nutrient Warning Labels compared to other labels (p < 0.001). Conclusions Nutrient Warning Labels were the only label that significantly reduced intent to purchase packaged foods containing excess levels of sugar or sodium among consumers in Ethiopia. Implementation of a mandatory policy requiring packaged foods to display Nutrient Warning Labels is recommended in Ethiopia. Trial Registration This trial was registered at https://www.clinicaltrials.gov on September 9, 2022 (NCT05549388).

INTRODUCTION:Excessive salt intake is a major risk factor for cardiovascular disease and premature mortality in China and globally. A recent cluster RCT demonstrated the effectiveness of home cook interventions in reducing salt intake and blood pressure among participants from 6 provinces in China. Yet, it remains unclear whether expanding these interventions across China would be cost-effective. METHODS:The China Cardiovascular Disease Prevention Model, a validated microsimulation model that captures the development and consequences of cardiovascular disease among adults aged ≥35 years in China, was used to estimate lifetime averted cardiovascular disease events and deaths, direct medical costs (2022 international dollar), quality-adjusted life years gained, and the incremental cost-effectiveness ratio of home cook interventions versus the status quo. Costs and quality-adjusted life years were discounted at 3%. RESULTS:Compared with the status quo, home cook interventions were projected to avert 1.97 million coronary heart disease events, 3.69 million stroke events, 0.77 million deaths due to coronary heart disease, and 1.29 million deaths due to stroke in women. The interventions would also avert 1.62 million coronary heart disease events, 3.8 million stroke events, 0.6 million deaths due to coronary heart disease, and 1.15 million deaths due to stroke in men. The interventions resulted in an incremental cost-effectiveness ratio of 3,552 international dollar per quality-adjusted life year in women and 5,445 international dollar per quality-adjusted life year in men and, thus, were cost-effective considering a willingness-to-pay threshold of 21,318 international dollar (1-time gross domestic product per capita). CONCLUSIONS:Public health policymakers in China should consider widely adopting home cook interventions to better prevent cardiovascular disease and reduce healthcare costs.

Fiscal food policies can be used, among others, to minimize the burden of diet-related diseases. To inform the design of such policies in Australia, we used the large grocery-purchasing dataset NielsenIQ Homescan to estimate own-price elasticities and cross-price elasticities for 18 food categories. We found that households were most responsive to changes in price for non-sugar-sweetened beverages and sugar-sweetened beverages: a 10% increase in price was associated with reductions in demand of 15% and 12%, respectively. Additionally, an increase in the price of one category was associated with relatively small changes in the quantity demanded for other categories (that is, 92% of cross-price elasticities had an absolute value <0.2). There were small differences in own-price and cross-price elasticities across socioeconomic quintiles. These price elasticity estimates can be used to model the health and equity impacts of fiscal food policies in Australia.

Objectives: To estimate the potential health benefits, costs, and cost-effectiveness of mandating a limit on industrial trans-fatty acids (iTFA) in all foods, fats, and oils in China. Methods: A multiple cohort proportional multistate life table model was used to project the impact of eliminating dietary iTFA on ischemic heart disease (IHD) burden and costs over different time horizons (5 years, 10 years, and population lifetime). Nationally representative data on iTFA intake were derived from the 2015-2018 China Total Diet Study and China National Health and Nutrition Survey 2011. The health benefits were modelled as averted IHD deaths, events, and health-adjusted life years (HALYs) gained. Net costs were estimated by combining healthcare costs and policy implementation costs, which included government monitoring and industry reformulation costs. Cost-effectiveness was assessed through incremental cost-effectiveness ratios, with both costs and HALYs discounted at 3%. Results: Over 10 years, the mandatory iTFA limit was estimated to prevent approximately 111K IHD deaths (95% uncertainty interval [UI]: 101K-120K), 744K IHD events (95% UI: 678K-807K), 330K HALYs (95% UI: 301K-357K), resulting in a healthcare cost saving of around 2.8 billion USD (95% UI: 2.5-3.0). Over the population lifetime, the intervention was projected to avert 1.9 million (95% UI: 1.7-2.0) IHD deaths, 3.4 million (95% UI: 3.0-3.7) IHD events, and 5.9 million (95% UI: 5.4-6.4) HALYs, saving approximately 5.1 billion USD (95% UI: 4.6-5.7) Policy implementation costs were estimated at 165 million USD (95% UI: 132-198) over the first 10 years and 295 million USD (95% UI: 261-329) over the population lifetime ( Figures 1-2 ). The intervention was estimated to be cost-saving regardless of the time horizon, with robust findings across sensitivity analyses. Conclusions These findings suggest that legislating a mandatory limit on iTFAs could be a cost-saving strategy to prevent a substantial number of IHD events and deaths in China.

Nigeria seeks to address the growing burden of hypertension and related diseases by reducing excessive dietary sodium through national dietary policymaking. This study aims to describe the levels and sources of dietary sodium intake among Nigerian adults to inform these policies. From June 2023 to July 2023, adults aged 18 to 69 years old were recruited from the Federal Capital Territory, Kano, and Ogun states to participate in a population-based, cross-sectional demographic health survey. Data were also collected to assess levels and dietary sources of sodium through four 24-h dietary recalls by trained study personnel. The primary analyses included the distribution of sodium intake and sources of sodium, in aggregate and by sex and state. Results were weighted to the Nigerian population. Multivariate regression models evaluated associations between baseline sociodemographic factors and sodium intake. Among 537 participants, 365 (68.0%) were female, median (IQR) age was 38 (27, 48) years, and 27.2% and 15.1% had a self-reported history of hypertension and cardiovascular disease, respectively. Most (90.7%) participants completed all 4 dietary recalls. Weighted median (IQR) daily sodium intake according to repeated 24-h dietary recalls was 3,876 (3,169, 4,783) mg per day with higher intake reported among males (3,832 [3,201, 4,658] mg/dl) compared with females (3,515 [2,859, 4,313], p < .0001). Nearly two-thirds (62.1%) of sodium came from discretionary sources, including 27.2% from salt and 32.5% from salty seasonings, 24.0% came from restaurant or street food, and 8.6% came from non-discretionary sources at home (i.e., sodium inherent in foods). Salt and salty seasonings added at the table accounted for 10.7% of sodium intake and was highest among females (21.6%) and males (16.2%) in Kano (p < .0001). On the other hand, sodium from street food was highest in males (35.7%) and females (34.2%) in Ogun. Older participants 60-69 years (adjusted beta [95% CI] = -332.8 mg (-639.0, -6.6) mg) had lower daily sodium intake compared to participants 30-44 years. Results were similar when excluding individuals with cardiovascular disease or hypertension. Adults in the Federal Capital Territory, Kano, and Ogun consume nearly twice the recommended level of dietary sodium. Most dietary sodium intake came from home cooked foods, nearly two-thirds of which were consumed from discretionary sources, which has important policy implications for dietary sodium policy implementation.