Salt Reduction Interventions in Sub-Saharan Africa: A Systematic Review

Background

Salt intake is associated with hypertension, the leading risk factor for cardiovascular disease. To promote population-level salt reduction, the World Health Organization recommends intervention around three core pillars: Reformulation of processed foods, consumer awareness, and environmental changes to increase availability and affordability of healthy food. This review investigates salt reduction interventions implemented and evaluated in sub-Saharan Africa (SSA).

Methods

MEDLINE and google scholar electronic databases were searched for articles meeting inclusion criteria. Studies that reported evaluation results of a salt intervention in SSA were identified. Titles and abstracts were screened, and articles selected for full-text review. Quality of included articles was assessed, and a narrative synthesis of the findings undertaken. PROSPERO registration number CRD42015019055.

Results

Seven studies representing four countries—South Africa, Nigeria, Ghana, and Tanzania—were included. Two examined product reformulation, one in hypertensive patients and the other in normotensive volunteers. Four examined consumer awareness interventions, including individualised counselling and advisory health sessions delivered to whole villages. One study used an environmental approach by offering discounts on healthy food purchases. All the interventions resulted in at least one significantly improved outcome measure including reduction in systolic blood pressure (BP), 24 hour urinary sodium excretion, or mean arterial BP.

Conclusions

More high quality studies on salt reduction interventions in the region are needed, particularly focused on consumer awareness and education in urban populations given the context of rapid urbanisation; and essentially, targeting product reformulation and environmental change, for greater promise for propagation across a vast, diverse continent.     

Health and Economic Impacts of Eight Different Dietary Salt Reduction Interventions

Background

Given the high importance of dietary sodium (salt) as a global disease risk factor, our objective was to compare the impact of eight sodium reduction interventions, including feasible and more theoretical ones, to assist prioritisation.

Methods

Epidemiological modelling and cost-utility analysis were performed using a Markov macro-simulation model. The setting was New Zealand (NZ) (2.3 million citizens, aged 35+ years) which has detailed individual-level administrative cost data.

Results

Of the most feasible interventions, the largest health gains were from (in descending order): (i) mandatory 25% reduction in sodium levels in all processed foods; (ii) the package of interventions performed in the United Kingdom (UK); (iii) mandatory 25% reduction in sodium levels in bread, processed meats and sauces; (iv) media campaign (as per a previous UK one); (v) voluntary food labelling as currently used in NZ; (vi) dietary counselling as currently used in NZ. Even larger health gains came from the more theoretical options of a “sinking lid” on the amount of food salt released to the national market to achieve an average adult intake of 2300 mg sodium/day (211,000 QALYs gained, 95% uncertainty interval: 170,000 – 255,000), and from a salt tax. All the interventions produced net cost savings (except counselling – albeit still cost-effective). Cost savings were especially large with the sinking lid (NZ$ 1.1 billion, US$ 0.7 billion). Also the salt tax would raise revenue (up to NZ$ 452 million/year). Health gain per person was greater for Māori (indigenous population) men and women compared to non-Māori.

Conclusions

This study substantially expands on the range of previously modelled salt reduction interventions and suggests that some of these might achieve major health gains and major cost savings (particularly the regulatory interventions). They could also reduce ethnic inequalities in health.     

A Standardized Vascular Disease Health Check in Europe: A Cost-Effectiveness Analysis

Background

No clinical trials have assessed the effects or cost-effectiveness of health check strategies to detect and manage vascular disease. We used a mathematical model to estimate the cost-effectiveness of several health check strategies in six European countries.

Methods

We used country-specific data from Denmark, France, Germany, Italy, Poland, and the United Kingdom to generate simulated populations of individuals aged 40–75 eligible for health checks in those countries (e.g. individuals without a previous diagnosis of diabetes, myocardial infarction, stroke, or serious chronic kidney disease). For each country, we used the Archimedes model to compare seven health check strategies consisting of assessments for diabetes, hypertension, lipids, and smoking. For patients diagnosed with vascular disease, treatment was simulated in a standard manner. We calculated the effects of each strategy on the incidence of type 2 diabetes, major adverse cardiovascular events (MACE), and microvascular complications in addition to quality of life, costs, and cost per quality-adjusted life-year (QALY).

Results

Compared with current care, health checks reduced the incidence of MACE (6–17 events prevented per 1000 people screened) and diabetes related microvasular complications (5–11 events prevented per 1000 people screened), and increased QALYs (31–59 discounted QALYs) over 30 years, in all countries. The cost per QALY of offering a health check to all individuals in the study cohort ranged from €14903 (France) to cost saving (Poland). Pre-screening the population and offering health checks only to higher risk individuals lowered the cost per QALY. Pre-screening on the basis of obesity had a cost per QALY of €10200 (France) or less, and pre-screening with a non-invasive risk score was similar.

Conclusions

A vascular disease health check would likely be cost effective at 30 years in Denmark, France, Germany, Italy, Poland, and the United Kingdom.     

Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study

Introduction

While evidence that alcohol pricing policies reduce alcohol-related health harm is robust, and alcohol taxation increases are a WHO “best buy” intervention, there is a lack of research comparing the scale and distribution across society of health impacts arising from alternative tax and price policy options. The aim of this study is to test whether four common alcohol taxation and pricing strategies differ in their impact on health inequalities.

Methods and Findings

An econometric epidemiological model was built with England 2014/2015 as the setting. Four pricing strategies implemented on top of the current tax were equalised to give the same 4.3% population-wide reduction in total alcohol-related mortality: current tax increase, a 13.4% all-product duty increase under the current UK system; a value-based tax, a 4.0% ad valorem tax based on product price; a strength-based tax, a volumetric tax of £0.22 per UK alcohol unit (= 8 g of ethanol); and minimum unit pricing, a minimum price threshold of £0.50 per unit, below which alcohol cannot be sold. Model inputs were calculated by combining data from representative household surveys on alcohol purchasing and consumption, administrative and healthcare data on 43 alcohol-attributable diseases, and published price elasticities and relative risk functions. Outcomes were annual per capita consumption, consumer spending, and alcohol-related deaths. Uncertainty was assessed via partial probabilistic sensitivity analysis (PSA) and scenario analysis.The pricing strategies differ as to how effects are distributed across the population, and, from a public health perspective, heavy drinkers in routine/manual occupations are a key group as they are at greatest risk of health harm from their drinking. Strength-based taxation and minimum unit pricing would have greater effects on mortality among drinkers in routine/manual occupations (particularly for heavy drinkers, where the estimated policy effects on mortality rates are as follows: current tax increase, −3.2%; value-based tax, −2.9%; strength-based tax, −6.1%; minimum unit pricing, −7.8%) and lesser impacts among drinkers in professional/managerial occupations (for heavy drinkers: current tax increase, −1.3%; value-based tax, −1.4%; strength-based tax, +0.2%; minimum unit pricing, +0.8%). Results from the PSA give slightly greater mean effects for both the routine/manual (current tax increase, −3.6% [95% uncertainty interval (UI) −6.1%, −0.6%]; value-based tax, −3.3% [UI −5.1%, −1.7%]; strength-based tax, −7.5% [UI −13.7%, −3.9%]; minimum unit pricing, −10.3% [UI −10.3%, −7.0%]) and professional/managerial occupation groups (current tax increase, −1.8% [UI −4.7%, +1.6%]; value-based tax, −1.9% [UI −3.6%, +0.4%]; strength-based tax, −0.8% [UI −6.9%, +4.0%]; minimum unit pricing, −0.7% [UI −5.6%, +3.6%]). Impacts of price changes on moderate drinkers were small regardless of income or socioeconomic group. Analysis of uncertainty shows that the relative effectiveness of the four policies is fairly stable, although uncertainty in the absolute scale of effects exists. Volumetric taxation and minimum unit pricing consistently outperform increasing the current tax or adding an ad valorem tax in terms of reducing mortality among the heaviest drinkers and reducing alcohol-related health inequalities (e.g., in the routine/manual occupation group, volumetric taxation reduces deaths more than increasing the current tax in 26 out of 30 probabilistic runs, minimum unit pricing reduces deaths more than volumetric tax in 21 out of 30 runs, and minimum unit pricing reduces deaths more than increasing the current tax in 30 out of 30 runs). Study limitations include reducing model complexity by not considering a largely ineffective ban on below-tax alcohol sales, special duty rates covering only small shares of the market, and the impact of tax fraud or retailer non-compliance with minimum unit prices.

Conclusions

Our model estimates that, compared to tax increases under the current system or introducing taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. We also estimate that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.     

Modelling the potential spread of Hyalomma marginatum ticks in Europe by migratory birds

This study modelled the probability of introduction of Hyalomma marginatum into Europe by predicting the potential migratory routes of 28 bird species and the probability to carry immatures of the tick. Flyways were modelled as a spatio-temporal feature, at weekly intervals, using satellite-derived data of temperature and vegetal phenology, together with cost surfaces derived from speed and direction of the wind (years 2002–2018). The expected period of activity of tick immatures defined the probability of ticks being carried by birds along the modelled flyways. The probability of moulting of the engorged nymphs was modelled as a linear relationship of the daily sum of temperatures after tick introduction by birds. Positive probabilities of tick introduction extend the known northern range of permanent populations to central and western France, and large portions of central Europe. The flight of birds into an area and thence the risk of introduction of H. marginatum is very heterogeneous, with sites receiving “waves” of different bird species at diverse times of the year. Therefore, there is not a clear period of time for introduction, as it depends on the modelled behaviour of the bird species. The probability of introduction into Baltic and Nordic countries is small. We hypothesise that conditions of a warmer climate might support permanent populations of H. marginatum if a high number of immatures is introduced. Active surveys in risky territories, where the tick is not yet established, are advisable for rapid intervention.     

Weight Gain following Pallidal Deep Brain Stimulation: A PET Study

The mechanisms behind weight gain following deep brain stimulation (DBS) surgery seem to be multifactorial and suspected depending on the target, either the subthalamic nucleus (STN) or the globus pallidus internus (GPi). Decreased energy expenditure following motor improvement and behavioral and/or metabolic changes are possible explanations. Focusing on GPi target, our objective was to analyze correlations between changes in brain metabolism (measured with PET) and weight gain following GPi-DBS in patients with Parkinson’s disease (PD). Body mass index was calculated and brain activity prospectively measured using 2-deoxy-2[18F]fluoro-D-glucose PET four months before and four months after the start of GPi-DBS in 19 PD patients. Dopaminergic medication was included in the analysis to control for its possible influence on brain metabolism. Body mass index increased significantly by 0.66 ± 1.3 kg/m2 (p = 0.040). There were correlations between weight gain and changes in brain metabolism in premotor areas, including the left and right superior gyri (Brodmann area, BA 6), left superior gyrus (BA 8), the dorsolateral prefrontal cortex (right middle gyrus, BAs 9 and 46), and the left and right somatosensory association cortices (BA 7). However, we found no correlation between weight gain and metabolic changes in limbic and associative areas. Additionally, there was a trend toward a correlation between reduced dyskinesia and weight gain (r = 0.428, p = 0.067). These findings suggest that, unlike STN-DBS, motor improvement is the major contributing factor for weight gain following GPi-DBS PD, confirming the motor selectivity of this target.     

Higher Adiponectin Levels Predict Greater Weight Gain in Healthy Women in the Nurses' Health Study

Adiponectin and resistin's possible roles in weight regulation have received little attention. We tested the hypothesis that adipokine levels predict future weight gain in women in the Nurses' Health Study. Among women who provided blood samples in 1990, we studied 1,063 women who did not develop diabetes (“healthy”) and 984 women who subsequently developed diabetes. Total and high‐molecular‐weight (HMW) adiponectin and resistin levels were measured using enzyme‐linked immunosorbent assay. Women who did not developed diabetes had a mean BMI of 26.3 ± 6.0 kg/m² at baseline and gained 2.0 ± 6.1 kg over 4 years. Women who developed diabetes had a mean BMI of 30.1 ± 5.4 kg/m² at baseline, and gained 2.4 ± 7.1 kg over 4 years. In women who did not developed diabetes, higher baseline levels of total and HMW adiponectin were associated with significantly greater weight gain after adjustment for age, BMI, physical activity, diet, and other covariates: women in the highest quintile of total adiponectin gained 3.18 kg compared to women in the lowest quintile who gained 0.80 kg (fully adjusted; P for trend <0.0001). Adiponectin was not significantly associated with weight gain in women who subsequently developed diabetes. Resistin levels were not associated with weight gain in either women who did or did not develop diabetes during the follow‐up. We conclude that elevated adiponectin levels are associated with higher weight gain in healthy women, independent of confounding risk factors. High adiponectin production by adipocytes might be a sign of “healthy” adipose tissue with further capacity to store fat.     

Political Regimes,Political Ideology,and Self-Rated Health in Europe: A Multilevel Analysis

Background

Studies on political ideology and health have found associations between individual ideology and health as well as between ecological measures of political ideology and health. Individual ideology and aggregate measures such as political regimes, however, were never examined simultaneously.

Methodology/Principal Findings

Using adjusted logistic multilevel models to analyze data on individuals from 29 European countries and Israel, we found that individual ideology and political regime are independently associated with self-rated health. Individuals with rightwing ideologies report better health than leftwing individuals. Respondents from Eastern Europe and former Soviet republics report poorer health than individuals from social democratic, liberal, Christian conservative, and former Mediterranean dictatorship countries. In contrast to individual ideology and political regimes, country level aggregations of individual ideology are not related to reporting poor health.

Conclusions/Significance

This study shows that although both individual political ideology and contextual political regime are independently associated with individuals'' self-rated health, individual political ideology appears to be more strongly associated with self-rated health than political regime.     

Modelling the spatial distribution of linear landscape elements in Europe

Linear landscape elements, such as ditches, hedgerows, lines of trees and field margins, provide important habitats and ecosystem services and function as ecological infrastructure for species within agricultural landscapes. Spatial maps of the distribution of these elements are needed to better represent landscape structure within regional scale environmental assessments. We present wall-to-wall maps for green lines, ditches and grass margins for Europe, using spatial modelling of ground observations on linear features from the 2009 LUCAS (land use/cover area frame statistical survey) database. We compare different spatial interpolation methods, ranging from spatial autocorrelation-based methods to methods that explain the occurrence of elements based on biophysical and socio-economic information. Our results are 1 km² resolution maps of the occurrence of linear landscape elements for Europe. Independent validation of green lines based on aerial photographs showed the best results for interpolation based on regionally estimated regressions relating the occurrence of landscape elements to environmental and socio-economic location factors. The results confirm the importance of the underlying biophysical and socio-economic factors on the presence and abundance of linear landscape elements. However, the total explanatory strength of the considered factors is moderate and a considerable uncertainty in the exact distribution remains.     

Health Impacts of Active Transportation in Europe

Policies that stimulate active transportation (walking and bicycling) have been related to heath benefits. This study aims to assess the potential health risks and benefits of promoting active transportation for commuting populations (age groups 16–64) in six European cities. We conducted a health impact assessment using two scenarios: increased cycling and increased walking. The primary outcome measure was all-cause mortality related to changes in physical activity level, exposure to fine particulate matter air pollution with a diameter <2.5 μm, as well as traffic fatalities in the cities of Barcelona, Basel, Copenhagen, Paris, Prague, and Warsaw. All scenarios produced health benefits in the six cities. An increase in bicycle trips to 35% of all trips (as in Copenhagen) produced the highest benefits among the different scenarios analysed in Warsaw 113 (76–163) annual deaths avoided, Prague 61 (29–104), Barcelona 37 (24–56), Paris 37 (18–64) and Basel 5 (3–9). An increase in walking trips to 50% of all trips (as in Paris) resulted in 19 (3–42) deaths avoided annually in Warsaw, 11(3–21) in Prague, 6 (4–9) in Basel, 3 (2–6) in Copenhagen and 3 (2–4) in Barcelona. The scenarios would also reduce carbon dioxide emissions in the six cities by 1,139 to 26,423 (metric tonnes per year). Policies to promote active transportation may produce health benefits, but these depend of the existing characteristics of the cities. Increased collaboration between health practitioners, transport specialists and urban planners will help to introduce the health perspective in transport policies and promote active transportation.     

Health and social inequality in Europe.

In most European countries health has been shown to be linked to social circumstances--gradients in health status have persisted for decades, despite major changes in the principal causes of death. In central and eastern Europe life expectancy has stagnated since the mid-60s, whereas in the West it has increased; but even in the West it is related to income distribution. Social differences in mortality in men are three times as large in some countries as in others, and are influenced by factors other than conventional risk factors. Substantial declines in mortality and morbidity could result from a narrowing of health inequalities even when differences in health risk between social groups are comparatively small. Policies to reduce health inequalities can be introduced in smaller communities and organisations such as the school and workplace. National policies are variable; factors generating inequalities require action across several policy areas.     

Lead Us Not into Tanktation: A Simulation Modelling Approach to Gain Insights into Incentives for Sporting Teams to Tank

Annual draft systems are the principal method used by teams in major sporting leagues to recruit amateur players. These draft systems frequently take one of three forms: a lottery style draft, a weighted draft, or a reverse-order draft. Reverse-order drafts can create incentives for teams to deliberately under-perform, or tank, due to the perceived gain from obtaining quality players at higher draft picks. This paper uses a dynamic simulation model that captures the key components of a win-maximising sporting league, including the amateur player draft, draft choice error, player productivity, and between-team competition, to explore how competitive balance and incentives to under-perform vary according to league characteristics. We find reverse-order drafts can lead to some teams cycling between success and failure and to other teams being stuck in mid-ranking positions for extended periods of time. We also find that an incentive for teams to tank exists, but that this incentive decreases (i) as uncertainty in the ability to determine quality players in the draft increases, (ii) as the number of teams in the league reduces, (iii) as team size decreases, and (iv) as the number of teams adopting a tanking strategy increases. Simulation models can be used to explore complex stochastic dynamic systems such as sports leagues, where managers face difficult decisions regarding the structure of their league and the desire to maintain competitive balance.     

Protein Thermal Stability Enhancement by Designing Salt Bridges: A Combined Computational and Experimental Study

Protein thermal stability is an important factor considered in medical and industrial applications. Many structural characteristics related to protein thermal stability have been elucidated, and increasing salt bridges is considered as one of the most efficient strategies to increase protein thermal stability. However, the accurate simulation of salt bridges remains difficult. In this study, a novel method for salt-bridge design was proposed based on the statistical analysis of 10,556 surface salt bridges on 6,493 X-ray protein structures. These salt bridges were first categorized based on pairing residues, secondary structure locations, and Cα–Cα distances. Pairing preferences generalized from statistical analysis were used to construct a salt-bridge pair index and utilized in a weighted electrostatic attraction model to find the effective pairings for designing salt bridges. The model was also coupled with B-factor, weighted contact number, relative solvent accessibility, and conservation prescreening to determine the residues appropriate for the thermal adaptive design of salt bridges. According to our method, eight putative salt-bridges were designed on a mesophilic β-glucosidase and 24 variants were constructed to verify the predictions. Six putative salt-bridges leaded to the increase of the enzyme thermal stability. A significant increase in melting temperature of 8.8, 4.8, 3.7, 1.3, 1.2, and 0.7°C of the putative salt-bridges N437K–D49, E96R–D28, E96K–D28, S440K–E70, T231K–D388, and Q277E–D282 was detected, respectively. Reversing the polarity of T231K–D388 to T231D–D388K resulted in a further increase in melting temperatures by 3.6°C, which may be caused by the transformation of an intra-subunit electrostatic interaction into an inter-subunit one depending on the local environment. The combination of the thermostable variants (N437K, E96R, T231D and D388K) generated a melting temperature increase of 15.7°C. Thus, this study demonstrated a novel method for the thermal adaptive design of salt bridges through inference of suitable positions and substitutions.     

Reengineering an Information System: A Case Study in Risk Reduction

Business-process reengineering (BPR), like computer information systems development (ISD), deals primarily with process and contains only weak facilities for addressing structure and culture. Manufacturing and ISD have strong roots in the functionalist traditions of natural science, and in a cultural environment their engineering stance deals poorly with obstacles to change. While the structured, or “hard,” engineering approaches have given rise to successful developments, they have not always proved effective. In ISD, the hard engineering methods have a tendency to redefine information systems problems as problems of technical development, and similarly in engineering contexts, BPR risks becoming too focused on technical processes. However, failure to gain commitment and a sense of ownership in new processes is a cause of failure in both BPR and ISD. This article explores a case study where both technical and human issues must be addressed—the extension of student record processing within a university. In this study, the BPR requirement is seen to arise from the users of the information system rather than as an imposed managerial imperative. The use of total systems intervention (TSI) and interactive planning (IP) enabled the immediate technical problems to be separated from underlying BPR requirements and from the need to gain commitment to change. Thus, unnecessary technical effort and the risks of failure from resistance to change were avoided. From the findings of this intervention, it is argued that the wider application of TSI provides a framework within which managerially perceived needs can be translated into a grassroots commitment.     

Novel Miscanthus hybrids: Modelling productivity on marginal land in Europe using dynamics of canopy development determined by light interception

New biomass crop hybrids for bioeconomic expansion require yield projections to determine their potential for strategic land use planning in the face of global challenges. Our biomass growth simulation incorporates radiation interception and conversion efficiency. Models often use leaf area to predict interception which is demanding to determine accurately, so instead we use low-cost rapid light interception measurements using a simple laboratory-made line ceptometer and relate the dynamics of canopy closure to thermal time, and to measurements of biomass. We apply the model to project the European biomass potentials of new market-ready hybrids for 2020–2030. Field measurements are easier to collect, the calibration is seasonally dynamic and reduces influence of weather variation between field sites. The model obtained is conservative, being calibrated by crops of varying establishment and varying maturity on less productive (marginal) land. This results in conservative projections of miscanthus hybrids for 2020–2030 based on 10% land use conversion of the least (productive) grassland and arable for farm diversification, which show a European potential of 80.7–89.7 Mt year⁻¹ biomass, with potential for 1.2–1.3 EJ year⁻¹ energy and 36.3–40.3 Mt year⁻¹ carbon capture, with seeded Miscanthus sacchariflorus × sinensis displaying highest yield potential. Simulated biomass projections must be viewed in light of the field measurements on less productive land with high soil water deficits. We are attempting to model the results from an ambitious and novel project combining new hybrids across Europe with agronomy which has not been perfected on less productive sites. Nevertheless, at the time of energy sourcing issues, seed-propagated miscanthus hybrids for the upscaled provision of bioenergy offer an alternative source of renewable energy. If European countries provide incentives for growers to invest, seeded hybrids can improve product availability and biomass yields over the current commercial miscanthus variety.