ESTIMATING THE HEALTH AND ECONOMIC EFFECTS OF THE VOLUNTARY SODIUM REDUCTION TARGETS IN BRAZIL: MICROSIMULATION ANALYSIS
Authors: Fernandes Nilson Eduardo Augusto , Pearson-Stuttard Jonathan , Collins Brendan , Guzman-Castillo Maria , Capewell Simon , O’Flaherty Martin , Jaime Patrícia Constante , Kypridemos Chris 
Published: February 2021

ABSTRACTObjectiveTo analyse the potential health and economic impact of the voluntary sodium reduction targets in Brazil, from 2013 to 2032.DesignModelling study. A microsimulation approach of a close-to-reality synthetic population (IMPACT NCD BR) was used to evaluate the potential health benefits of setting voluntary upper limits for sodium content as part of Brazilian government strategy. The model estimates cardiovascular disease (CVD) deaths and cases prevented or postponed, and disease treatment costs.Model inputs were informed by the 2013 National Health Survey, the 2008-2009 Household Budget Survey, and high-quality meta-analyses to inform model inputs. Costs included costs of the National Health System on CVD treatment and informal care costs.SettingSynthetic population with similar characteristics to the community dwelling population of Brazil.ParticipantsSynthetic people with traits informed by the national surveys of Brazil.Main outcome measuresCardiovascular disease cases and deaths prevented or postponed by 2032, over a 20-year period (2013-2032), stratified by age and sex.ResultsApplying the voluntary sodium targets between 2013 and 2032 could prevent or postpone approximately 112,000 CVD cases (95% Uncertainty Intervals UI: 28,000 to 258,000) among men and 70,000 cases among women (95% UI: 16,000 to 167,000), and also prevent or postpone approximately 2,600 CVD deaths (95% UI: −1,000 to 11,000), 55% in men. The policy could also produce a net cost saving of approximately US$ 222 million (95% UI: US$ 53.6-524.4 million) in medical costs to the Brazilian National Health System for the treatment of CHD and stroke, and save approximately US$ 71 million (95% UI: US$ 17.1-166.9 million) in informal costs.ConclusionsBrazilian voluntary sodium targets could generate substantial health and economic impacts. Further progress in lower, more comprehensive thresholds for sodium in foods and strategies for reducing other sodium sources could maximise the health and economic benefits to the population. This is the first IMPACT NCD microsimulation model adapted to a Latin American country and represents a big step forward for using models to inform policy in the region. The results indicate that sodium reduction targets must go further and faster in order to achieve national and international commitments.WHAT IS ALREADY KNOWN ON THIS TOPIC-Public-private partnerships (PPPs), including voluntary targets for the reduction of critical nutrients, such as sodium, sugars and fats, through food reformulation, have been promoted as effective strategies for addressing dietary factors for non-communicable disease prevention.-Salt (sodium chloride) intake is a leading dietary risk factor for cardiovascular disease (CVD) globally. Over 27 thousand deaths from coronary heart disease and stroke are attributable to excessive sodium intake in Brazil every year. About 20% of sodium in the Brazilian diet comes from industrialized foods, and over 70% come from added table salt and salt-based condiments.-Since 2011, Brazil has implemented a voluntary approach for reducing sodium in processed and ultra-processed foods, including salt-based condiments. Nevertheless, national targets have not matched the targets of other countries in the Region of the Americas and globally, and target compliance has not been achieved across the entire Brazilian food market.WHAT THIS STUDY ADDS-We estimated the impact of the current sodium reduction targets in Brazil, by analysing individual-level food category consumption and sodium intake.-Using the first IMPACT NCD microsimulation model adapted to the Latin American context, we estimated that if applied between 2013 and 2032, the voluntary targets could potentially have prevented approximately 180,000 CVD cases and 2,500 CVD deaths. The case reductions might save approximately US$ 220 million in CVD-related medical costs (hospitalizations, outpatient and primary health care and pharmaceutical treatment) and some US$ 70 million in informal costs.-More impactful sodium reductions in Brazil may not be achieved without more stringent and comprehensive targets; for instance, mandatory rather than voluntary policy formulation, including policies aimed at reducing the consumption of discretionary table salt.