Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012

Authors

  • B Nojilana Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
  • N Abdelatif Biostatistics Research Unit, South African Medical Research Council, Cape Town, South Africa
  • A Cois Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
  • A E Schutte School of Population Health, University of New South Wales, Sydney, Australia; The George Institute for Global Health, Sydney, Australia; Hypertension in Africa Research Team, South African Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
  • E Wentzel-Viljoen Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
  • E B Turuwa Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
  • R A Roomaney Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
  • O F Awotiwon Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
  • I Neethling Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; Institute for Lifecourse Development, Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
  • R Pacella Institute for Lifecourse Development, Faculty of Education, Health and Human Sciences, University of Greenwich, London, UK
  • V Pillay-van Wyk Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
  • D Bradshaw Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; Department of Family Medicine and Public Health, Faculty of Health Sciences, University of Cape Town, South Africa

DOI:

https://doi.org/10.7196/SAMJ.2022.v112i8b.16490

Keywords:

Hypretension, cardiovascular disease

Abstract

Background. Elevated sodium consumption is associated with increased blood pressure, a major risk factor for cardiovascular and chronic kidney disease.
Objectives. To quantify the deaths and disability-adjusted life years (DALYs) attributed to high sodium intake in persons aged ≥25 years in South Africa (SA) for 2000, 2006 and 2012.
Methods. Comparative risk assessment (CRA) methodology was used and population attributable fractions (PAFs) of high sodium intake, mediated through high blood pressure (BP), for cardiovascular and chronic kidney disease were estimated. This was done by taking the difference between the PAF for elevated systolic BP (SBP) based on the estimated SBP level in the population and the PAF based on the estimated SBP that would result if sodium intake levels were reduced to the theoretical minimum risk exposure level (1 g/day) according to population group and hypertension categories. A meta-regression based on data from nine national surveys conducted between 1998 and 2017 was used to estimate the prevalence of hypertension by age, sex and population group. Relative risks identified from international literature were used and the difference in PAFs was applied to local burden estimates from the second South African National Burden of Disease Study. Age-standardised rates were calculated using World Health Organization (WHO) standard population weights. The attributable burden was also estimated for 2012 using an alternative target of 2 g/day proposed in the National Strategic Plan for the Prevention and Control of Non-communicable Diseases (NSP).
Results. High sodium intake as mediated through high SBP was estimated to cause 8 071 (95% uncertainty interval (UI) 6 542 - 15 474)
deaths in 2012, a drop from 9 574 (95% UI 8 158 - 16 526) in 2006 and 8 431 (95% UI 6 972 - 14 511) in 2000. In 2012, ischaemic heart
disease caused the highest number of deaths in persons (n=1 832), followed by haemorrhagic stroke (n=1 771), ischaemic stroke (n=1 484) and then hypertensive heart disease (n=1 230). Ischaemic heart disease was the highest contributor to deaths for males (27%), whereas for females it was haemorrhagic stroke (23%). In 2012, 1.5% (95% UI 1.3 - 2.9) of total deaths and 0.7% (95% UI 0.6 - 1.2) of total DALYs were attributed to high sodium intake. If the NSP target of <2 g/day sodium intake had been achieved in 2012, ~2 943 deaths and 48 870 DALYs would have been averted.
Conclusion. Despite a slight decreasing trend since 2006, high sodium intake mediated through raised BP accounted for a sizeable burden of disease in 2012. Realising SA’s target to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation.

References

Nojilana B, Bradshaw D, Pillay-vanWyk V, et al. Emerging trends in non-communicable disease mortality in South Africa, 1997 - 2010. S Afr Med J 2016;106(5):477-484. https://doi.org/10.7196/ SAMJ.2016.v106i5.10674

Bradshaw D, Steyn K, Levitt N, et al. Non-communicable diseases – a race against time. Cape Town: South African Medical Research Council, 2011. https://www.samrc.ac.za/sites/default/files/ attachments/2016-06-27/raceagainst.pdf (accessed November 2016).

Mayosi BM, Lawn JE, van Niekerk A, et al. Health in South Africa: Changes and challenges since 2009. Lancet 2012;380(9858):2029-2943. https://doi.org/10.1016/s0140-6736(12)61814-5

Gómez-Olivé FX, Ali SA, Made F, et al. Regional and sex differences in the prevalence and awareness of hypertension: An H3Africa AWI-Gen Study across 6 sites in sub-Saharan Africa. Glob Heart 2017;12(2):81-90. https://doi.org/10.1016/j.gheart.2017.01.007

DzudieA,KengneAP,MunaWFT,etal.Prevalence,awareness,treatmentandcontrolofhypertension in a self-selected sub-Saharan African urban population: A cross-sectional study. BMJ Open 2012;2(4):e001217. https://doi.org/10.1136/bmjopen-2012-001217

Ware LJ, Charlton K, Schutte AE, et al. Associations between dietary salt, potassium and blood pressure in South African adults: WHO SAGE Wave 2 Salt & Tobacco. Nutr Metab Cardiovasc Dis 2017;27(9):784-791. https://doi.org/10.1016/j.numecd.2017.06.017

Zhao D, Qi Y, Zheng ZZ, et al. Dietary factors associated with hypertension. Nat Rev Cardiol 2011;8(8):456-465. https://doi.org/10.1038/nrcardio.2011.75

World Health Organization. A global brief on hypertension. Geneva: WHO, 2013. https://www.who. int/publications/i/item/a-global-brief-on-hypertension-silent-killer-global-public-health-crisis- world-health-day-2013 (accessed January 2018).

Van Vliet BN, Campbell NR. Canadian Hypertension Education Program efforts to reduce sodium intake in Canada: Why, what, and when? Can J Cardiol 2011;27(4):437-445. https://doi.org/10.1016/j. cjca.2011.04.012

Tibazarwa KB, Damasceno AA. Hypertension in developing countries. Can J Cardiol 2014;30(5):527- 533. https://doi.org/10.1016/j.cjca.2014.02.020

He FJ, MacGregor GA. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2009;23(6):363-384. https://doi.org/10.1038/ jhh.2008.144

Strazzullo P, D’Elia L, Kandala NB, et al. Salt intake, stroke, and cardiovascular disease: Meta-analysis of prospective studies. BMJ 2009;339:b4567. https://doi.org/10.1136/bmj.b4567

Frieden TR. Sodium reduction – saving lives by putting choice into consumers’ hands. JAMA 2016;316(6):579-580. https://doi.org/10.1001/jama.2016.7992

Zhang J, Guo X, Lu Z, et al. Cardiovascular diseases deaths attributable to high sodium intake in Shandong Province, China. J Am Heart Assoc 2019;8(1):1-11. https://doi.org/10.1161/ JAHA.118.010737

Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Cochrane Database Syst Rev 2011, Issue 11. Art. No.: CD004022. https://doi.org/10.1002/14651858.CD004022.pub3

Mente A, O’Donnell MJ, Rangarajan S, et al. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med 2014;371(7):601-611. https://doi.org/10.1056/NEJMoa1311989

He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane

systematic review and meta-analysis of randomised trials. BMJ 2013;346:f1325. https://doi.

org/10.1136/bmj.f1325

Taylor RS, Ashton KE, Moxham T, et al. Reduced dietary salt for the prevention of cardiovascular disease: A meta-analysis of randomised controlled trials (Cochrane review). Am J Hypertens 2011;24(8):843-853. https://doi.org/10.1038/ajh.2011.115

Institute of Medicine. Sodium Intake in Populations: Assessment of the Evidence. Washington, DC: National Academies Press, 2013.

O’Donnell M, Mente A, Alderman MH, et al. Salt and cardiovascular disease: Insufficient evidence to recommend low sodium intake. Eur Heart J 2020;41(35):3363-3373. https://doi.org/10.1093/eurheartj/ ehaa586

WorldHealthOrganization.Guideline:Potassiumintakeforadultsandchildren.Geneva:WHO,2014. http://www.who.int/nutrition/publications/guidelines/potassium_intake/en/ (accessed 20 July 2016).

World Health Organization. Guideline: Sodium intake for adults and children. Geneva: WHO, 2012. https://www.who.int/publications/i/item/9789241504836 (accessed November 2017).

GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990 - 2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2019;393(10184):1958-1972. https://doi. org/10.1016/S0140-6736(19)30041-8

Charlton KE, Steyn K, Levitt NS, et al. Diet and blood pressure in South Africa: Intake of foods containing sodium, potassium, calcium and magnesium in three ethnic groups. Nutrition 2005;21(1):39-50. https://doi.org/10.1016/j.nut.2004.09.007

Charlton KE, Steyn K, Levitt NS, et al. A food-based randomised controlled trial to assess the impact of dietary manipulation of cations on blood pressure in hypertensive South Africans. Publ Health Nutr 2008;11(12):1397-1406.

Maseko MJ, Majane HO, Milne J, et al. Salt intake in an urban, developing South African community. Cardiovasc J S Afr 2006;17(4):186-191.

Swanepoel B, Schutte AE, Cockeran M, et al. Sodium and potassium intake in South Africa: An evaluation of 24-hour urine collections in a white, black, and Indian population. J Am Soc Hypertens 2016;10(11):829-837. https://doi.org/10.1016/j.jash.2016.08.007

South Africa. Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act No. 54 of 1972). Regulations Relating to the Reduction of Sodium in Certain Foodstuffs and Related Matters (R214). Pretoria: Government Gazette No. 36274. 2013. https://www.gov.za/sites/default/files/gcis_ document/201710/41164gon1071.pdf (accessed November 2014).

National Department of Health, South Africa. National Strategic Plan for the Prevention and Control of Non-communicable Diseases 2013 - 17. Pretoria: NDoH, 2013. http://www.hsrc.ac.za/uploads/ pageContent/3893/NCDs%20STRAT%20PLAN%20%20CONTENT%208%20april%20proof.pdf (accessed 1 October 2013).

Norman R, Bradshaw D, Schneider M, et al. A comparative risk assessment for South Africa in 2000: Towards promoting health and preventing disease. S Afr Med J 2007;97(8 Pt 2):637-641.

Bertram MY, Steyn K, Wentzel-Viljoen E, et al. Reducing the sodium content of high-salt foods: Effect on cardiovascular disease in South Africa. S Afr Med J 2012;102(9):743-745. https://doi.org/10.7196/ SAMJ.5832

He FJ, Campbell NRC, MacGregor GA. Reducing salt intake to prevent hypertension and cardiovascular disease. Rev Panam Salud Publica 2012;32(4):293-300. https://doi.org/10.1590/s1020- 49892012001000008

Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med 2014;371:624-634. https://doi.org/10.1056/NEJMoa1304127

Nojilana B, Abdelatif N, Cois A, et al. Estimating the changing burden of disease attributable to high blood pressure in South Africa in 2000, 2006 and 2012. S Afr Med J 2022;112(8b):571-581 https://doi. org/10.7196/SAMJ.2022.v112i8b.16542

Lim SS, Vos T, Flaxman AD, et al. 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 2012;380(9859):2224-2260. https://doi. org/10.1016/S0140-6736(12)61766-8

Morris RC Jr, Sebastian A, Forman A, et al. Normotensive salt sensitivity: Effects of race and dietary potassium. Hypertension 1999;33(1):18-23. https://doi.org/10.1161/01.hyp.33.1.1837

Gafane-Matemane LF, Mokae NL, Breet Y, et al. Associations of central and peripheral blood pressure with the renin-angiotensin-aldosterone system in healthy young adults: The African-PREDICT study. Hypertens Res 2021;44(4):435-445. https://doi.org/10.1038/s41440-020-00566-1

National Department of Health, South Africa, and Macro International. South Africa Demographic and Health Survey 1998. Pretoria: Department of Health, South Africa, 2002. https://dhsprogram.com/ pubs/pdf/FR206/FR206.pdf (accessed May 2017).

National Department of Health, South Africa, Medical Research Council, OrcMacro. South Africa Demographic and Health Survey 2003. Pretoria: Department of Health, 2007. https://dhsprogram. com/pubs/pdf/FR206/FR206.pdf (accessed July 2017).

National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. South Africa Demographic and Health Survey 2016. Pretoria, South Africa, and Rockville, Md, USA: NDoH, Stats SA, SAMRC, and ICF, 2017. www.statssa.gov.za/ publications/Report%2003-00-09/Report%2003-00-092016.pdf (accessed January 2018).

Southern Africa Labour and Development Research Unit. National Income Dynamics Study Wave 1, 2008 [dataset]. Version 6.1 Cape Town: SALDRU, 2009. https://microdata.worldbank.org/index.php/ catalog/900/study-description (accessed March 2019).

Southern Africa Labour and Development Research Unit. National Income Dynamics Study Wave 2, 2010 - 2011 [dataset]. Version 4.0.0. Cape Town: SALDRU, 2016. https://microdata.worldbank.org/ index.php/catalog/1294/study-description (accessed June 2019).

Southern Africa Labour and Development Research Unit. National Income Dynamics Study Wave 3, 2012 [dataset]. Version 2.1. Cape Town: SALDRU, 2014. https://datacatalog.worldbank.org/dataset/ south-africa-national-income-dynamics-study-2012 (accessed September 2020).

Southern Africa Labour and Development Research Unit. National Income Dynamics Study Wave 4, 2014 - 2015 [dataset]. Version 2.0.0. Cape Town: SALDRU, 2016. https://microdata.worldbank.org/ index.php/catalog/2595 (accessed October 2020).

Southern Africa Labour and Development Research Unit. National Income Dynamics Study Wave 5, 2017 [dataset]. Version 1.0.0. 2017. https://doi.org/10.25828/fw3h-v708

Shisana O, Labadarios D, Rehle T, et al. The South African National Health and Nutrition Examination Survey (SANHANES-1). Cape Town: Human Sciences Research Council, 2013. http://www.hsrc.ac.za/ uploads/pageNews/72/SANHANES-launch%20edition%20(online%20version).pdf (accessed July 2017).

Zhou B, Bentham J, di Cesare M, et al. Worldwide trends in blood pressure from 1975 to 2015: A pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet 2017;389(10064):37-55. https://doi.org/10.1016/S0140-6736(16)31919-5

Doi SAR, Barendregt JJ, Khan S, et al. Advances in the meta-analysis of heterogeneous clinical trials II: The quality effects model. Contemp Clin Trials 2015;45(Pt A):123-129. https://doi.org/10.1016/j. cct.2015.05.010

Pillay-van Wyk V, Roomaney R, Awotiwon OF, et al. Burden of Disease Review Manager for Systematic Review of Observational Studies: Technical report and user guide. Cape Town: South African Medical Research Council, 2018. https://www.samrc.ac.za/sites/default/files/files/2021-12-01/ BODREVMAN%20Technical%20User%20GuideV2_0.pdf (accessed October 2018).

Pillay-van Wyk V, Msemburi W, Laubscher R, et al. Mortality trends and differentials in South Africa from 1997 to 2012: Second National Burden of Disease Study. Lancet Glob Health 2016;4(9):e642-e653. https://doi.org/10.1016/S2214-109X(16)30113-9

Dorrington R. Alternative South African mid-year estimates. Cape Town: University of Cape Town, 2013. http://www.commerce.uct.ac.za/Research_Units/CARE/Monographs/Monographs/mono13.pdf (accessed 20 October 2020).

Ahmad OB, Boschi-Pinto C, Lopez AD, et al. Age standardisation of rates: A new WHO standard. Geneva: World Health Organization, 2001.

Barendregt JJ. Ersatz version 1.5. 2017. http://www.epigear.com (accessed January 2019).

Barendregt JJ. The effect size in uncertainty analysis. Value Health 2010;13(4):388-391. https://doi.

org/10.1111/j.1524-4733.2009.00686.x

Pillay van Wyk V, Dorrington R, Bradshaw D. Rapidly changing mortality profiles in South Africa in its nine provinces. S Afr Med J 2017;107(3):168-169. https://doi.org/10.7196/SAMJ.2017.v107i3.12344

Newson RS, Elmadfa I, Biro G, et al. Barriers for progress in salt reduction in the general population. An international study. Appetite 2013;71:22-31. https://doi.org/10.1016/j.appet.2013.07.003

Wentzel-Viljoen E, Steyn K, Ketterer E, et al. Use salt and foods high in salt sparingly: A food-based dietary guideline for South Africa. S Afr J Clin Nutr 2013;26(3):S105-S13.

Gibney M, Vorster H. South African food-based dietary guidelines. S Afr J Clin Nutr 2001;4(3):S2.

Burger R, Christian CS, Gerdtham UG, et al. Use of simulated patients to assess hypertension case management at public healthcare facilities in South Africa. J Hypertens 2020;38(2):362-367. https://doi.org/10.1097/hjh.0000000000002258

Southern African Hypertension Society. Guidelines for the management of hypertension at primary health care level. S Afr Med J 1995;85(12 Pt 2):1321-1325.

Charlton KE, Corso B, Ware L, et al. Effect of South Africa’s interim mandatory salt reduction programme on urinary sodium excretion and blood pressure. Prev Med Rep 2021;23:101469. https:// doi.org/10.1016/j.pmedr.2021.101469

GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990 - 2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396(10258):12041222. https://doi.org/10.1016/S0140-6736(20)30925-9

Watkins DA, Olson ZD, Verguet S, et al. Cardiovascular disease and impoverishment averted due to a salt reduction policy in South Africa: An extended cost-effectiveness analysis. Health Policy Plan 2016;31(1):75-82. http:// doi.org/10.1093/heapol/czv023

Watkins DA, Nugent R, Saxenian H, et al. Intersectoral policy priorities for health. In: Mock CN, Kobusingye O, Nugent R, Smith KR, eds. Injury Prevention and Environmental Health: Key Messages from This Volume. Disease Control Priorities. 3rd ed. Injury Prevention and Environmental Health, 7. Washington, DC: World Bank, 2017.

He FJ, Brinsden HC, Macgregor GA. Salt reduction in the United Kingdom: A successful experiment in public health. J Hum Hypertens 2014;28(6):345-352. https://doi.org/10.1038/jhh.2013.105

Wentzel-Viljoen E, Steyn K, Lombard C, et al. Evaluation of a mass-media campaign to increase the awareness of the need to reduce discretionary salt use in the South African population. Nutrients 2017;9(11):1238. https://doi.org/10.3390/nu9111238

Micha R, Khatibzadeh S, Shi P. Global, regional and national consumption of major food groups in 1990 and 2010: A systematic analysis including 266 country-specific nutrition surveys worldwide. BMJ Open 2015;5(9):e008705. https://doi.org/10.1136/bmjopen-2015-008705

Afshin A, Micha R, Khatibzadeh S, et al. Dietary policies to reduce non-communicable diseases. In: Brown GW, Yamey G, Wamala S, eds. The Handbook of Global Health Policy. 1st ed. Chichester: John Wiley & Sons, 2014:175-193. https://doi.org/10.1002/9781118509623.ch9

Charlton K, Ware LJ, Chidumwa G, et al. Prediction of 24-hour sodium excretion from spot urine samples in South African adults: A comparison of four equations. J Hum Hypertens 2020;34(1):24-33. https://doi.org/10.1038/s41371-019-0210-2

Ahuja JKC, Pehrsson PR, Haytowitz DB, et al. Sodium monitoring in commercially processed and restaurant foods. Am J Clin Nutr 2015;101(3):622-631. https://doi.org/10.3945/ajcn.114.084954

Wentzel-Viljoen E, Laubscher R, Vorster H. Changes in food intake from 2005 to 2010 by a cohort of black rural and urban African men and women in the North West Province of South Africa: The PURE-NWP-SA study. Public Health Nutr 2018;21(16):2941-2958. https://doi.org/10.1017/ S1368980018001878

Ndanuko R, Ibrahim R, Hapsari R, Neale E, Raubenheimer D, Charlton KE. Association between the urinary sodium to potassium ratio and blood pressure in adults: A systematic review and meta analysis. Adv Nutr 2021;12(5):1751-1757. https://doi.org/10.1093/advances/nmab036

Downloads

Published

2022-09-30

How to Cite

1.
Nojilana B, Abdelatif N, Cois A, Schutte AE, Wentzel-Viljoen E, Turuwa EB, et al. Estimating the changing burden of disease attributable to high sodium intake in South Africa for 2000, 2006 and 2012. S Afr Med J [Internet]. 2022 Sep. 30 [cited 2024 Sep. 14];112(8B):627-38. Available from: https://samajournals.co.za/index.php/samj/article/view/203

Similar Articles

1-10 of 126

You may also start an advanced similarity search for this article.

Most read articles by the same author(s)

1 2 > >>