Skip to main content Accessibility help

Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review

  • Elisabeth Schorling (a1), Dea Niebuhr (a2) and Anja Kroke (a3)



To analyse and compare the cost-effectiveness of different interventions to reduce salt consumption.


A systematic review of published cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) was undertaken in the databases EMBASE, MEDLINE (PubMed), Cochrane and others until July 2016. Study selection was limited to CEA and CUA conducted in member countries of the Organisation for Economic Co-operation and Development (OECD) in English, German or French, without time limit. Outcomes measures were life years gained (LYG), disability-adjusted life years (DALY) and quality-adjusted life years (QALY). Relevant aspects in modelling were analysed and compared. Quality assessments were conducted using the Drummond and Jefferson/British Medical Journal checklist.


OECD member countries.


Mainly adults.


Fourteen CEA and CUA were included in the review which analysed different strategies: salt reduction or substitution in processed foods, taxes, labelling, awareness campaigns and targeted dietary advice. Fifty-nine out of sixty-two scenarios were cost-saving. The incremental cost-effectiveness ratio in international dollars (Intl.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (<−3072 Intl.$/QALY, −6187 Intl.$/LYG and <584 Intl.$/DALY over the time horizon compared with the status quo or no intervention). Targeted dietary advice was rather not cost-effective (24 600 Intl.$/QALY and >303 900 Intl.$/DALY). However, only six studies analysed cost-effectiveness from a societal perspective and quality assessments showed flaws in conducting and a lack of transparency in reporting.


A population-wide salt reduction could be cost-effective in prevention of hypertension and CVD in OECD member countries. However, comparability between study results is limited due to differences in modelling, applied perspectives and considered data.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review
      Available formats


Corresponding author

* Corresponding author: Email


Hide All
1. Lim, SS, Vos, T, Flaxman, AD et al. (2012) A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 22242260.
2. World Health Organization (2009) Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: WHO.
3. Appel, LJ (2006) Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 47, 296308.
4. Dickinson, HO, Mason, JM, Nicolson, DJ et al. (2006) Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. J Hypertens 24, 215233.
5. Mozaffarian, D, Fahimi, S, Singh, GM et al. (2014) Global sodium consumption and death from cardiovascular causes. N Engl J Med 371, 624634.
6. He, FJ, Li, J & MacGregor, GA (2013) Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev issue 4, CD004937.
7. Aburto, NJ, Ziolkovska, A, Hooper, L et al. (2013) Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ 346, f1326.
8. Graudal, NA, Hubeck-Graudal, T & Jurgens, G (2011) Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane Database Syst Rev issue 11, CD004022.
9. Strazzullo, P, D’Elia, L, Kandala, N et al. (2009) Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ 339, b4567.
10. World Health Organization (2012) Guideline: Sodium Intake for Adults and Children. Geneva: WHO.
11. Brown, IJ, Tzoulaki, I, Candeias, V et al. (2009) Salt intakes around the world: implications for public health. Int J Epidemiol 38, 791813.
12. Bloom, DE, Cafiero, ET, Jané-Llopis, E et al. (2011) The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum.
13. McLaren, L (2012) Policy Options for Reducing Dietary Sodium Intake. SPP Research Papers vol. 5, no. 20. Calgary: University of Calgary.
14. Cappuccio, FP, Capewell, S, Lincoln, P et al. (2011) Policy options to reduce population salt intake. BMJ 343, d4995.
15. Rose, G (1985) Sick individuals and sick populations. Int J Epidemiol 14, 3238.
16. Knorpp, L & Kroke, A (2010) Salzreduktion als bevölkerungsbezogene Präventionsmaßnahme. Teil 3: Vorteile des Ansatzes und kritische Betrachtung möglicher adverser Effekte. Ernährungs Umschau 57, 410415.
17. World Health Organization (2013) Mapping Salt Reduction Initiatives in the WHO European Region. Copenhagen: WHO Regional Office for Europe.
18. European Commission (2012) Survey on Members States’ Implementation of the EU Salt Reduction Framework. Brussels: European Union.
19. Webster, JL, Dunford, EK, Hawkes, C et al. (2011) Salt reduction initiatives around the world. J Hypertens 29, 10431050.
20. Karppanen, H & Mervaala, E (2006) Sodium intake and hypertension. Prog Cardiovasc Dis 49, 5975.
21. Hughes, R & Margetts, BM (2011) Practical Public Health Nutrition. Oxford: Wiley-Blackwell.
22. Appel, LJ, Angell, SY, Cobb, LK et al. (2012) Population-wide sodium reduction: the bumpy road from evidence to policy. Ann Epidemiol 22, 417425.
23. Knorpp, L & Kroke, A (2012) Evidence-based public health nutrition: what constitutes good evidence? CAB Rev 7, 122.
24. Drummond, MF, Sculpher, MJ, Torrance, GW et al. (2005) Methods for the Economic Evaluation of Health Care Programmes, 3rd ed. Oxford: Oxford University Press.
25. Wang, G & Bowman, BA (2013) Recent economic evaluations of interventions to prevent cardiovascular disease by reducing sodium intake. Curr Atheroscler Rep 15, 349.
26. Wang, G & Labarthe, D (2011) The cost-effectiveness of interventions designed to reduce sodium intake. J Hypertens 29, 16931699.
27. Neal, B (2007) The Effectiveness and Costs of Population Interventions to Reduce Salt Consumption. Background paper to the WHO Forum and Technical Meeting on ‘Reducing Salt Intake in Populations’, 5–7 October 2006, Paris, France. Geneva: WHO.
28. Centre for Reviews and Dissemination (2009) Systematic Reviews: CRD’s Guidance for Undertaking Reviews in Health Care. York: CRD, University of York.
29. Organisation for Economic Co-operation and Development (2016) Purchasing power parities (PPP) for GDP. (accessed May 2016).
30. Organisation for Economic Co-operation and Development (2016) Price deflator. (accessed May 2016).
31. Drummond, MF & Jefferson, TO (1996) Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ 313, 275283.
32. Nghiem, N, Blakely, T, Cobiac, LJ et al. (2016) The health gains and cost savings of dietary salt reduction interventions, with equity and age distributional aspects. BMC Public Health 16, 423.
33. Wilson, N, Nghiem, N, Eyles, H et al. (2016) Modeling health gains and cost savings for ten dietary salt reduction targets. Nutr J 15, 44.
34. Nghiem, N, Blakely, T, Cobiac, LJ et al. (2015) Health and economic impacts of eight different dietary salt reduction interventions. PLoS One 10, e0123915.
35. Collins, M, Mason, H, O’Flaherty, M et al. (2014) An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. Value Health 17, 517524.
36. Mason, H, Shoaibi, A, Ghandour, R et al. (2014) A cost effectiveness analysis of salt reduction policies to reduce coronary heart disease in four Eastern Mediterranean countries. PLoS One 9, e84445.
37. Cobiac, LJ, Magnus, A, Lim, S et al. (2012) Which interventions offer best value for money in primary prevention of cardiovascular disease? PLoS One 7, e41842.
38. Dodhia, H, Phillips, K, Zannou, M et al. (2012) Modelling the impact on avoidable cardiovascular disease burden and costs of interventions to lower SBP in the England population. J Hypertens 30, 217226.
39. Barton, P, Andronis, L, Briggs, A et al. (2011) Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study. BMJ 343, d4044.
40. Martikainen, JA, Soini, EJO, Laaksonen, DE et al. (2011) 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 65, 11481155.
41. Bibbins-Domingo, K, Chertow, GM, Coxson, PG et al. (2010) Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 362, 590599.
42. Cobiac, LJ, Vos, T & Veerman, JL (2010) Cost-effectiveness of interventions to reduce dietary salt intake. Heart 96, 19201925.
43. Smith-Spangler, CM, Juusola, JL, Enns, EA et al. (2010) Population strategies to decrease sodium intake and the burden of cardiovascular disease: a cost-effectiveness analysis. Ann Intern Med 152, 481487.
44. Murray, CJL, Lauer, JA, Hutubessy, RCW et al. (2003) Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet 361, 717725.
45. Selmer, RM, Kristiansen, I, Haglerød, A et al. (2000) Cost and health consequences of reducing the population intake of salt. J Epidemiol Community Health 54, 697702.
46. World Health Organization (2007) Reducing Salt Intake in Populations: Report of a WHO Forum and Technical Meeting. Geneva: WHO.
47. High Level Group on Diet Physical Activity and Health (2008) EU Framework for national salt initiatives. (accessed March 2016).
48. Kanzler, S, Hartmann, C, Gruber, A et al. (2014) Salt as a public health challenge in continental European convenience and ready meals. Public Health Nutr 17, 24592466.
49. Girgis, S, Neal, B, Prescott, J et al. (2003) A one-quarter reduction in the salt content of bread can be made without detection. Eur J Clin Nutr 57, 616620.
50. World Health Organization (2011) Prevention and Control of NCDs: Priorities for Investment: Discussion Paper. First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control (Moscow, 28–29 April 2011). Geneva: WHO.
51. Taylor, RS, Ashton, KE, Moxham, T et al. (2011) Reduced dietary salt for the prevention of cardiovascular disease: a meta-analysis of randomized controlled trials (Cochrane review). Am J Hypertens 24, 843853.
52. O’Donnell, M, Mente, A, Rangarajan, S et al. (2014) Urinary sodium and potassium excretion, mortality, and cardiovascular events. N Engl J Med 371, 612623.
53. Lewington, S, Clarke, R, Qizilbash, N et al. (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 360, 19031913.
54. Penney, S (2009) Dropping the Salt: Practical Steps Countries are Taking to Prevent Chronic Non-Communicable Diseases through Population-Wide Dietary Salt Reduction. Ottawa: Public Health Agency of Canada.
55. Mytton, O, Gray, A, Rayner, M et al. (2007) Could targeted food taxes improve health? J Epidemiol Community Health 61, 689694.
56. He, FJ & MacGregor, GA (2009) A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 23, 363384.
57. Reinhold, T, Brüggenjürgen, B, Schlander, M et al. (2010) Economic analysis based on multinational studies: methods for adapting findings to national contexts. J Public Health 18, 327335.
58. National Institute for Health and Clinical Excellence (2010) Prevention of Cardiovascular Disease. NICE Public Health Guidance 25. Manchester: NICE.
59. Anderson, R (2010) Systematic reviews of economic evaluations: utility or futility? Health Econ 19, 350364.


Type Description Title
Supplementary materials

Schorling et al. supplementary material
Table S1

 PDF (128 KB)
128 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed