Stakeholder perspectives on scaling up potassium-enriched salt to reduce cardiovascular disease in Australia: a qualitative study

Excess sodium consumption, mostly from dietary salt, causes high blood pressure and an increased risk of cardiovascular disease(1). In parallel, insufficient potassium intake also contributes to raised blood pressure(2). Switching regular salt for potassium-enriched salt, where a proportion of the sodium chloride is replaced with potassium chloride, is a promising public health intervention to address both these issues(3). However, the supply chain to support increased use of potassium-enriched salt in Australia is not well understood. The objectives of this study were to investigate how the salt supply chain operates in Australia and to obtain food industry stakeholder perspectives on the technical barriers and enablers to increased potassium-enriched salt use. Twelve interviews with industry stakeholders (from food companies, salt manufacturers and trade associations) were conducted and thematically analysed using a template analysis method. Two top-level themes were developed: ‘supply chain practices’ and ‘technical barriers and enablers’. The potassium-enriched salt supply chain was described as less well-established than the low-cost production and distribution of regular salt in Australia. However, food companies reported not having difficulty sourcing potassium chloride. For Australian food industry stakeholders, cost, flavour and functionality were perceived as key barriers to increased uptake of potassium-enriched salt as a food ingredient. Stakeholders from food companies were hesitant to use potassium-enriched salt due to concerns about bitter or metallic flavours and uncertainty whether it would provide the same microbial/shelf-life functions or textural quality as regular salt. However, potassium-enriched salt manufacturers had divergent opinions stating potassium-enriched salt was a suitable functional replacement for regular salt and that flavour differences observed may be due to the incorrect use of potassium chloride as opposed to use of a purpose-made potassium-enriched salt. Stakeholders identified that establishing a stable and affordable supply of potassium-enriched salt in Australia and increased support for food technology research and development would enable increased use. To improve uptake of potassium-enriched salt by the Australian food industry, future efforts should focus on strengthening potassium-enriched salt supply chains and improving appeal for food industry to use in manufacturing and for consumers to purchase. Public health advocacy efforts should ensure that industry is equipped with the latest evidence on the feasibility and benefits of using potassium-enriched salt as an ingredient. Ongoing engagement is critical to ensure that industry is aware of their responsibility and opportunity to offer healthier foods to consumers by switching regular salt to potassium-enriched salt within foods.

The adverse effects of excess dietary sodium intake on blood pressure levels are well-established. On average the world eats dietary sodium, mostly in the form of salt, at twice the level recommended by the World Health Organization and five times the level consumed during a million years of hominid evolution. At the same time, average dietary potassium intake is below recommended intake levels in many populations, and inadequate potassium intake is also associated with high blood pressure. Potassium-enriched salt substitute, in which some of the sodium chloride is replaced with potassium chloride, was first showed to lower blood pressure more than a decade ago. Most recently, in 2021, the Salt Substitute and Stroke Study showed that potassium-enriched salt can also reduce the risks of stroke (rate ratio 14%; p = 0.006), major cardiovascular events (13%; p < 0.001) and premature death (12%; p < 0.001). This large-scale randomised trial done amongst 21,000 individuals followed for 5 years also showed that these benefits were achieved without harm, and in particular, with no evidence of hyperkalemia (rate ratio 1.04; p = 0.76). Potassium-enriched salts are a pragmatic means of reducing dietary sodium intake and supplementing dietary potassium intake in parallel. Unlike many other sodium reduction strategies, they are easy to implement because potassium-enriched salt can be used in just the same way as regular salt. This provided for excellent adherence in the Salt Substitute and Stroke Study, with 93% of participants still using the salt substitute at the end of the study. The potential health gains from a switch to potassium-enriched salt are very large. Modelling done for China indicates that about 1 million strokes and heart attacks could be prevented each year if the switch was made nationwide. Several million more events might be averted if implementation was global. Another key feature of potassium-enriched salt is that it can be provided at low cost. While on average about twice as expensive as regular salt, potassium-enriched salt has a median price of less than $3 per kilogram in low- and middle-income countries. Over the last 50 years, the fight against iodine deficiency disorders has seen the global salt supply switched from salt to iodized salt. It is now time to make a second switch from iodized salt to iodized and potassium-enriched salt to also prevent blood pressure related diseases.

To construct a whole-of-system model to inform strategies that reduce the burden of cardiovascular disease (CVD) in Australia. A system dynamics model was developed with a multidisciplinary modelling consortium. The model population comprised Australians aged 40 years and over, and the scope encompassed acute and chronic CVD as well as primary and secondary prevention. Health outcomes were CVD-related deaths and hospitalisations, and economic outcomes were the net benefit from both the healthcare system and societal perspectives. The eight strategies broadly included creating social and physical environments supportive of a healthy lifestyle, increasing the use of preventive treatments, and improving systems response to acute CVD events. The effects of strategies were estimated as relative differences to the business-as-usual between 2019-2039. Probabilistic sensitivity analysis produced uncertainty intervals of interquartile ranges (IQR). The greatest reduction in CVD-related deaths was seen in strategies that improve systems response to acute CVD events (8.9%, IQR: 7.7-10.2%), yet they resulted in an increase in CVD-related hospitalisations due to future recurrent admissions (1.6%, IQR: 0.1-2.3%). This flow-on effect highlighted the importance of addressing underlying CVD risks. On the other hand, strategies targeting the broad environment that supports a healthy lifestyle were effective in reducing both hospitalisations (7.1%; IQR: 5.0-9.5%) and deaths (8.1% reduction; IQR: 7.1-8.9%). They also produced an economic net benefit of AU$43.3 billion (IQR: 37.7-48.7) using a societal perspective, largely driven by productivity gains. Overall, strategic planning to reduce the burden of CVD should consider the varying effects of strategies over time and beyond the health sector.

This paper used official mortality data for Australia; data on incidence of coronary events and levels of risk factors from the World Health Organization's MONICA Project (to MONItor trends and determinants of CArdiovascular disease) in Newcastle, New South Wales, Australia; and national data on coronary procedures and medications to show the past trends and present situation of cardiovascular disease (CVD) in Australia. There are well-established trends of declining rates of deaths from all causes, CVD, coronary heart disease and stroke and of non- fatal coronary events (which are also becoming less severe). The three major risk factors of cigarette smoking, high blood pressure and high blood cholesterol have also been declining for some time. Despite this picture, which is encouraging from a population perspective, the medical costs of CVD are rising. This is due to increases in medical and surgical procedures and the use of increasingly expensive drugs. The challenge for public health is to keep the focus on prevention, including attention to the increasing prevalence of overweight and obesity. J Epidemiol, 1996 ; 6 : S209-S213.

Analysis of primary prevention services for cardiovascular disease in Australia's community pharmacies

Cardiovascular disease (CVD), the leading cause of death globally and in Australia, is sensitive to heat exposure. This study assesses the burden of CVD attributable to high temperatures across Australia and projects future burden in the context of climate change. Disability-adjusted life years for CVD, including years of life lost and years lived with disability, were sourced from the Australian Burden of Disease database. A meta-regression model was constructed using location-specific predictors and relative risks from prior literature to estimate relative risks of CVD mortality and morbidity due to high temperatures in the Australian context. The baseline CVD burden attributable to high temperatures in Australia for 2003-18 was calculated, and future burdens under two greenhouse gas emissions scenarios [Representative Concentration Pathways (RCP4.5 and RCP8.5)] for the 2030s and 2050s were projected, considering demographic changes and human adaptation. During the baseline period, high temperatures accounted for 7.3% (95% confidence interval: 7.0%-7.6%) of the CVD burden in Australia, equivalent to 223.8 Disability-adjusted life years (95% confidence interval: 221.0-226.6) per 100 000 population. Future projections suggest a steady increase in the CVD burden across all scenarios examined. By the 2050s, under the RCP8.5 scenario that considers population growth and no adaptation, the total attributable burden of CVD is projected to more than double compared with the baseline, with the Northern Territory facing the most significant increase. These impacts could be mitigated with effective human adaptation to the warming climate. Higher temperatures are expected to exacerbate the burden of CVD. This study highlights the need for urgent adaptation and mitigation efforts to minimize the negative health impacts of a warming climate on CVD.

Objective The aim of this study was to understand, from the perspective of policy makers, who holds the responsibility for driving evidence-based policy to reduce the high burden of cardiovascular disease (CVD) in rural Australia. Methods Qualitative interviews were conducted with policy makers at the local, state and federal government levels in Australia (n=21). Analysis was conducted using the Conceptual Framework for Understanding Rural and Remote Health to understand perceptions of policy makers around who holds the key responsibility in driving evidence-based policy. Results At all levels of government, there were multiple examples of disconnect in the understanding of who is responsible for driving the generation of evidence-based policy to reduce CVD in rural areas. Policy makers suggested that the rural communities themselves, health services, health professionals, researchers and the health sector as a whole hold large responsibilities in driving evidence-based policy to address CVD in rural areas. Within government, there was also a noticeable disconnect, with local participants feeling it was the federal government that held this responsibility; however, federal government participants suggested this was largely a local government issue. Overall, there seemed to be a lack of responsibility for CVD policy, which is reflected in a lack of action in rural areas. Conclusion There was a lack of clarity about who is responsible for driving evidence-based policy generation to address the high burden of CVD in Australia, providing one possible explanation for the lack of policy action. Clarity among policy makers over shared roles and leadership for policy making must be addressed to overcome the current burden of CVD in rural communities. What is known about the topic? Rural health inequalities, such as the increased burden of CVD in rural Australia are persistent. Such health inequalities are unjust, with global theory suggesting political processes have facilitated, in part, the inequalities. With similar examples observed internationally in rural areas, little is known about the influence of the perspectives of policy makers regarding who is responsible for addressing health issues in rural areas, in the government context. What does this paper add? This paper provides empirical evidence, for all levels of government in Australia, that there is a lack of clarity in policy roles and responsibilities to address the unequal burden of CVD in rural Australia, at all levels of government. The paper provides evidence to support the urgent need for clarity within government around policy stakeholder roles. Without such clarity, it is unlikely that national-level progress in addressing rural health inequalities will be achieved in the near future. What are the implications for practitioners? Addressing ambiguity around who is responsible for the development of evidence-based policy to address the high burden of CVD in rural areas must be a high priority to ensure health disparities do not persist for future Australian generations. The results reported here are highly relevant to the Australian context, but also reflect similar findings internationally, namely that a lack of clarity among policy stakeholders appears to contribute to reduced action in addressing preventable health inequalities in disadvantaged populations. This paper provides evidence for policy makers and public health professionals to advocate for clear policy roles and direction in rural Australia.

Cardiovascular disease remains the leading cause of death in Australia, with primary care playing a crucial role in early intervention. This study aims to understand the facilitators and barriers to collaboration in primary care for the management of cardiovascular disease in Australia. This qualitative study used semi-structured interviews with maximum purposive sampling to capture general practitioners' perspectives on factors that impact collaboration between general practitioners and allied health professionals in cardiovascular disease management. The consolidated framework for implementation research was used to guide the analysis. General practitioners (n=23) across New South Wales were interviewed. Facilitators of collaboration included pre-established professional relationships, effective communication, existing co-location, severity of cardiovascular disease and perceived improvements in patient outcomes. Barriers identified included limited allied health availability, time constraints, complex referral processes, poor communication, low health literacy, inadequate remuneration and the view that collaboration is less necessary for patients with milder cardiovascular disease. Ultimately, the success of collaboration hinges on supportive organisational structures and strong professional relationships. Prioritising systemic integration of primary care with allied health services could improve cardiovascular disease risk and chronic disease management.

To estimate the health and economic burden of new and established cardiovascular disease from 2020 to 2029 in Australia. A two-stage multistate dynamic model was developed to predict the burden of the incident and prevalent cardiovascular disease, for Australians 40-90 years old from 2020 to 2029. The model captured morbidity, mortality, years of life lived, quality-adjusted life years, healthcare costs, and productivity losses. Cardiovascular risk for the primary prevention population was derived using Australian demographic data and the Pooled Cohort Equation. Risk for the secondary prevention population was derived from the REACH registry. Input data for costs and utilities were extracted from published sources. All outcomes were annually discounted by 5%. A number of sensitivity analyses were undertaken to test the robustness of the study. Between 2020 and 2029, the model estimates 377 754 fatal and 991 375 non-fatal cardiovascular events. By 2029, 1 061 756 Australians will have prevalent cardiovascular disease (CVD). The population accrued 8 815 271 [95% uncertainty interval (UI) 8 805 083-8 841 432] years of life lived with CVD and 5 876 975 (5 551 484-6 226 045) QALYs. The total healthcare costs of CVD were projected to exceed Australian dollars (AUD) 61.89 (61.79-88.66) billion, and productivity losses will account for AUD 78.75 (49.40-295.25) billion, driving the total cost to surpass AUD 140.65 (123.13-370.23) billion. Cardiovascular disease in Australia has substantial impacts in terms of morbidity, mortality, and lost revenue to the healthcare system and the society. Our modelling provides important information for decision making in relation to the future burden of cardiovascular disease.

Cost-effectiveness of Interventions to Prevent Cardiovascular Disease in Australia's Indigenous Population

548 Secondary Prevention of Cardiovascular Disease in Australia - an Update

Sodium is an essential dietary component, but excess sodium intake can lead to high blood pressure and an increased risk of cardiovascular disease. Many national and international bodies, including the World Health Organization, have advocated for population-wide sodium reduction interventions. Most have been unsuccessful due to inadequate sodium reduction by food industry and difficulties in persuading consumers to add less salt to food. Recent research highlights potassium-enriched salt as a new, feasible, acceptable, and scalable approach to reducing the harms caused by excess sodium and inadequate potassium consumption. Modeling shows that a global switch from regular salt to potassium-enriched salt has the potential to avert millions of strokes, heart attacks, and premature deaths worldwide each year. There will be many challenges in switching the world’s salt supply to potassium-enriched salt, but the success of universal salt iodization shows that making a global change to the manufacture and use of salt is a tractable proposition. This in-depth review of universal salt iodization identified the importance of a multisectoral effort with strong global leadership, the support of multilateral organizations, engagement with the salt industry, empowered incountry teams, strong participation of national governments, understanding the salt supply chain, and a strategic advocacy and communication plan. Key challenges to the implementation of the iodization program were costs to government, industry, and consumers, industry concerns about consumer acceptability, variance in the size and capabilities of salt producers, inconsistent quality control, ineffective regulation, and trade-related regulatory issues. Many of the opportunities and challenges to universal salt iodization will likely also be applicable to switching the global salt supply to iodized and potassium-enriched salt.

718 Cardiovascular Causes of Maternal Death in Australia - A Nationwide Autopsy Study

Cardiovascular disease (CVD) is a major cause of death globally. In advanced stages, patients with CVD often require palliative care due to reduced health-related quality of life from physical, psychological and spiritual symptoms, along with physical disability. To investigate (1) the symptom and function burden of patients with CVD on their first admission to specialist palliative care services and (2) how these care burdens, and other clinical characteristics, affected patients' utilisation of community-based versus inpatient services. A national population-based observational study using point-of-care outcomes sourced from the Australian palliative care outcomes and collaboration (PCOC). Community-based and inpatient Specialist palliative care services across Australia registered in the PCOC. Patients who required specialist palliative care principally for CVD, and whose death occurred between 1 January 2013 and 31 December 2022. Five validated clinical instruments were used to collect point-of-care outcomes on each individual's function (Resource Utilisation Groups - Activities of Daily Living (RUG) & Australia-modified Karnofsky Performance Status (AKPS)), symptom distress (Symptoms Assessment Scale & Palliative Care Problem Severity Score) and other clinical characteristics (Palliative Care Phases). Multivariable logistic regression was applied to evaluate how patients' functional and symptom burden influenced their use of inpatient versus community-based palliative care services. Our analysis included 17 002 patients with CVD, with 7539 (44.3%) receiving community palliative care services and 9463 (55.7%) accessing inpatient palliative care services. On admission to palliative care services, patients often exhibit significant physical functional impairments and substantial symptom burdens, particularly related to fatigue and breathing difficulties. In comparison, patients accessing inpatient services tended to have greater functional impairment (p<0.001) but commonly reported lower symptom burdens (p<0.001). Our analysis indicated that greater functional impairment (ORs ranged from 2.53 to 6.02, p<0.001 for RUG; ORs ranged from 1.72 to 5.02, p<0.008 for AKPS), poorer overall health condition (OR ranged from 1.28 to 17.60, p<0.001) and referrals by a community service (OR=0.16, 95% CI: 0.14 to 0.18, p<0.001) were a negative predictor of inpatient services use. Surprisingly, higher levels of symptom distress and challenges in symptom management were associated with a decreased likelihood of using inpatient services compared with community-based services. Patients with CVD frequently require support to manage decreased functional abilities, as well as symptoms like fatigue and breathing difficulties. With greater investment in community-based supportive services and a skilled palliative care workforce, more individuals with advanced CVD could potentially receive palliative care in community settings.

Depuis une quinzaine d'annees l'Australie, les Etats-Unis ainsi que d'autres pays montrent un declin spectaculaire de la mortalite due aux cardiopathies coronaires et aux infarctus du myocarde. Ce declin a suscite un vif interet a la fois sur les plans cliniques et epidemiologiques. Il a coincide avec un declin de la mortalite due aux maladies cerebrovasculaires et aux maladies liees a l'hypertension arterielle