RESEARCH ARTICLE Open Access
Ca dio ascula disease and high blood
p essu e end analyses om 2002 o 2016:
a e he implemen a ion o a sal
educ ion s a egy
D. Ab eu
1*
, P. Sousa
1,2
, C. Ma ias-Dias
3
and F. J. Pin o
4,5
Abs ac
Backg ound: Ca dio ascula disease (CVD) is he leading cause o dea h a ound he wo ld; howe e , many CVD
e en s could be p e en ed i we ocused on modi ica ion o he main isk ac o s.
Inc eased sal consump ion is es ima ed o ha e caused millions o dea hs, mos ly ela ed o CVD, pa icula ly
s oke, which is he leading cause o dea h in Po ugal.
In ou s udy, we aim o assess ends in he p opo ion o high blood p essu e (HBP) in Acu e Co ona y Synd ome
(ACS) pa ien s as well as he ends in s oke and ACS in Po ugal, especially a e a se o public heal h ini ia i es
we e implemen ed o educe sal in ake.
Me hods: The mon hly p opo ion o ACS pa ien s p esen ing wi h p e iously diagnosed HBP and he mon hly a e o
CVD admissions in o public hospi als in Po ugal we e calcula ed. CVD a es we e s a i ied in o ACS a e and s oke a es.
Da a we e s a i ied by demog aphics a iables. An in e up ed ime-se ies model was used o assess changes o e ime.
Resul s: B eakpoin analysis e ealed an es ima ed b eakpoin a ound he yea 2013 o he p opo ion o HBP pa ien s,
he ollowing yea he e was a dec easing end, howe e i was no signi ican . Analyses showed he end be o e
2013 was inc easing and s a ed o dec ease a e his yea . This dec eased in p opo ion o HBP pa ien s can be
ansla ed in o a educ ion o 555 people pe yea p esen ing wi h HBP in he ACS popula ion.
We analysed ends o ACS and s oke and es ed he signi icance o a b eakpoin in he yea 2013. Al hough none o
he emaining ends we e signi ican o ACS c ude a es and s oke c ude a e, a dec easing end was obse ed.
Conclusions: This esea ch p o ides an indica ion abou he impac a popula ion-wide app oach o CVD isk ac o s
has on CVD ends hemsel es. Ou esul s sugges ha popula ion-wide app oaches can ha e an impac on he
p e en ion and imp o emen o CVD con ol, educing he numbe o CVD e en s, and e en ually educing p ema u e
dea h by CVD. As mo e es ic ions on sal in ake a e being planned in Po ugal in he nex yea s, i is highly ele an o
assess wha is he cu en pano ama and wha u he educ ions we can expec .
Keywo ds: Ca dio ascula disease, High blood p essu e, Popula ion wide-app oach, Public heal h
* Co espondence: [email p o ec ed]
1
Escola Nacional de Saúde Pública, Uni e sidade No a de Lisboa, A enida
Pad e C uz, 1600-560 Lisboa, Po ugal
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Ab eu e al. BMC Public Heal h (2018) 18:722
h ps://doi.o g/10.1186/s12889-018-5634-z
Backg ound
Ca dio ascula disease (CVD) is he leading cause o dea h
a ound he wo ld [1]. An es ima ed 4 million people in
Eu ope die by CVD annually [2]. Howe e , many o he
CVD e en s could be p e en ed i we ocused on modi i-
ca ion o he main isk ac o s [3].
In 2010, high blood p essu e (HBP) was he leading isk
ac o con ibu ing o global disease bu den, accoun ing
o mo e han 15% o all heal h loss in adul s [4], and
esponsible o 62% o all s okes and 49% o ACS e en s
[5]. Al hough sodium is an essen ial nu ien necessa y o
main enance o plasma olume, acid-base balance, ans-
mission o ne e impulses, and no mal cell unc ion [6],
cu en sal consump ion is much g ea e han needed o
su i al, c ea ing an o e load on he me abolic sys em [7].
This o e load can inc ease blood p essu e (BP) [8].
Inc eased sal consump ion is es ima ed o ha e caused
millions o dea hs, mos ly ela ed o CVD, pa icula ly
s oke, which is he leading cause o dea h in Po ugal [9],
being one o he coun ies wi h he highes mo ali y a es
by s oke among he Wes e n coun ies [10]. The high
p e alence o HBP is poin ed o as one o he main easons.
Implemen ing bo h popula ion-wide and high- isk ap-
p oaches o educe blood p essu e seems almos ine i able
due o he la ge bu den o HBP [11,12]. E en small educ-
ions o HBP p e alence in he popula ion could lead o
g ea heal h gains. Knowing he impo ance o hese
app oaches, he Wo ld Heal h O ganiza ion (WHO) c ea ed
a se o ecommenda ions o educe die a y sal o 5 g/day,
in o de o p e en ch onic disease and imp o e heal h [13].
In he Eu opean Union, 26 ou o he 53 Membe S a es, in-
cluding Po ugal, implemen ed ope a ional sal educ ion
policies including laws aiming o educe sal in ake. Recen
epo s ha e shown ha sal consump ion in Po ugal has
been declining in ecen decades o a minimum o 7.3 g/day
in 2016 [14]. P ospec i e s udies ha e shown ha educing
sal in ake can lead o educ ions in blood p essu e and,
e en ually, o a educ ion in CVD e en s [15].
By 2010 a se o public heal h ini ia i es we e imple-
men ed in Po ugal, namely a educ ion in sal added o
b ead and manda o y sal labelling in p e-packed ood. As
hese ini ia i es a e mean o educe sal in ake we hypo h-
esized ha i could lead o a educ ion in he p opo ion o
HBP and CVD, namely ACS and s oke. The e o e in ou
s udy, we aim o assess he ends in he p opo ion o
HBP in ACS pa ien s, as well as he ends in s oke and
ACS in he coun y, be o e and a e hese ini ia i es we e
applied. Fo he sake o cla i y in ou s udy we e e as sal
o all sodium da a.
Me hods
S udy popula ion
Two popula ion se s we e used in his s udy. App o al
o access da a was ob ained p e iously. Fo bo h se s
o da a, pa icipan s included in he s udy we e o e
20 yea s old.
Fi s popula ion da ase
The Na ional Regis y o Acu e Co ona y Synd ome
(NRACS) [16]. All da a om 2002 o 2015 we e ex ac ed
o ou s udy. This da ase was used o ob ain he p opo -
ion o ACS pa ien s p e iously diagnosed wi h HBP. This
egis e collec s in o ma ion o ACS only, no jus o isk
ac o s bu also demog aphics.
This da ase has he ad an age o being in eg a ed in o
he Eu o Hea Su ey pla o m and, consequen ly, uses
he Ca diology Audi and Regis a ion Da a S anda ds
(CARDS) sys em. This sys em ensu es ha c edible and
compa able in o ma ion is collec ed in se e al Eu opean
coun ies o e ime as hey use s anda dised in o ma ion,
bo h in e ms o he de ini ion and coding o a iables,
and in he o m o measu emen and collec ion o da a.
As his da a is alida ed and s anda dised, i can be
applied o and used o alida e analyses in o he la ge
popula ions, hus being able o ob ain mo e obus
esul s [17]. HBP in his da ase was de ined as p e iously
diagnosed by a physician, o known blood p essu e >
140 mmHg sys olic o > 90 mmHg dias olic on wo o
mo e occasions.
Second popula ion da ase
TheNa ionalda abase ha collec sda a omalladmis-
sions in o Po uguese public hospi als (Mainland Po ugal).
Da a om 2002 o 2016 we e ex ac ed o ou s udy. This
da abase uses he Diagnosis Rela ed G oup (DRG) sys em
holding da a on p ima y diagnosis and some demog aphic
a iables, such as sex and age, as well as he geog aphic
egion o admission [18]. DRG codes o ischemic and
haemo hagic s oke we e included in he analysis
(ICD 9 h codes o s oke: 43301, 43321, 43311, 43331,
43391, 43401, 43411, 43491, 431, 432, 4320, 4321,
4329, and 43381) as well as codes o ACS (ICD 9 h
codes: 410.00–410.xx o iden i y admissions diagnosed
as Acu e Myoca dial In a c ion and code 4130 o iden i y
uns able angina).
The wo da ase s we e analysed sepa a ely as he e is
no possible me hod o iden i y he pa icipan s in he
da ase , hus he same pa icipan can in ac be egis-
e ed in bo h da ase s, howe e as he ou comes s ud-
ied a e independen om each o he we do no expec
his ac o in luence on he alidi y o he analysis.
Simila ly he ac ha he wo da ase s used in ou
s udy a e ca e ully moni o ed by he Po uguese Socie y
o Ca diology, in he case o he NRACS, and he
Di ec o a e o Gene al Heal h, in he case o he DRG
da a, ensu es he alidi y o hese da a.
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 2 o 9
S a is ical analysis
Two main ou comes we e analysed in ou s udy, he
mon hly p opo ion o ACS pa ien s p esen ing wi h
p e iously diagnosed HBP and he mon hly a e o CVD
admission in o public hospi als in he coun y. CVD
a es we e s a i ied in o ACS a e and s oke a es.
The p opo ion o ACS pa ien s wi h HBP was ob ained
by di iding he numbe o mon hly HBP diagnoses by he
o al ACS pa ien s egis e ed o mon h.
We applied an in e up ed ime se ies design, imple-
men ing a segmen ed mul iple linea eg ession model, in
which he esponse a iable was he mon hly he p opo -
ion o ACS pa ien s wi h HBP. These models a e use ul
when he ela ionship be ween he esponse and he inde-
penden a iables a e piecewise linea , namely ep esen ed
by wo o mo e s aigh lines connec ed a unknown
alues, which a e usually e e ed o as b eakpoin s. In ou
case, he b eakpoin would be expec ed o any gi en yea
whe e he e was a change in he end o he p opo ion
o pa ien s wi h HBP.
R“segmen ed”package was used o de e mine he
p esence o any b eakpoin s in he ends ound.
C ude e en a es o ACS and s oke (pe 100,000
adul s) we e compu ed o each mon h, using he popula-
ion o he coun y, es ic ed o he popula ion esiden
in mainland Po ugal, wi h ages o e 20 yea s as he
denomina o . C ude a es we e calcula ed as he numbe
o e en s, o each ou come sepa a ely, di ided by he
Po uguese popula ion o ha mon h.
As he e ec o his ype o popula ion wide app oaches
migh no be immedia e [19,20], aking some ime o
show e ec s in he popula ion, we used he es ima ed
b eakpoin om he mon hly p opo ion o ACS pa ien s
wi h HBP as a p oxy o he e ec o he es ima ed b eak-
poin in CVD ends.
The impac o he b eakpoin es ima ed on he CVD
ends, was assessed h ough a mul iple linea eg ession
model using s anda d me hods o in e up ed ime se ies.
We included one dicho omous a iable ha accoun ed
o he main e ec on hospi al admissions o he es ima ed
b eakpoin o he p opo ion o HBP pa ien s and an
in e ac ion be ween he b eakpoin es ima ed and ime, o
e alua e changes o e ime ollowing he b eakpoin .
This model was implemen ed in o de o es whe he
he e was a signi ican change in he numbe o e en s,
and i he e was any change in he p opo ion o HBP
pa ien s was obse ed.
A mon h indica o co a iable was in oduced o adjus
o seasonali y in he ou comes admissions.
All analyses we e s a i ied by sex and age. Age was
g ouped in o wo ca ego ies < 65 and ≥65 yea s old.
Au oco ela ion be ween mon h es ima es was inco po-
a ed adequa ely in o he model, wi h he p esence o sho
e m au oco ela ion applying a i s o de au o eg essi e -
AR (1) - s uc u e o he esiduals. Models we e i ed in R
e sion 2.3.2 so wa e.
S a is ical signi icance was assessed h ough p- alues,
assuming < 5% as signi ican and 95% con idence in e als
(CI) we e calcula ed o each o he eg ession coe icien s.
Resul s
A o al o 43,271 ACS e en s we e egis e ed in he
NRACS o e he las 14 yea s. The p opo ion o males
p esen ing wi h ACS has been consis en ly highe han
women, wi h a ound 69% o ACS e en s occu ing in
males. Mean age h ough he yea s o s udy has also
been ai ly s eady, anging om 65 o 66 yea s old
(Table 1). Male/ emale a io o HBP pa ien s (Fig. 1)
has also emained ai ly s eady h ough he yea s in he
ACS popula ion.
The p opo ions o pa ien s wi h HBP anged om a
minimum p opo ion o 50.0% o a maximum o 79.2%.
B eakpoin analysis e ealed an es ima ed b eakpoin
a ound he yea 2013 o he p opo ion o HBP pa ien s
(Fig. 2), he yea a e he e is a dec easing end, howe e
i was no signi ican (p- alue = 0.832). Analyses showed
he end be o e 2013 was, in ac , inc easing and s a ed
o dec ease a e his yea (β
be o e
= 0.009, CI: 0.007, 0.011;
β
a e
=−0.003, CI: -0.037, 0.0302). Al hough ze o is
p esen in he CI o he slope a e 2013, he change
be ween bo h slopes (be o e and a e 2013) is nega i e
wi h a dec ease o −0.012 in he mon hly p opo ion.
Thus, he dec ease es ima ed a e 2013 is highe han
he inc ease es ima ed be o e 2013. This dec ease in
p opo ion can be ansla ed in o a educ ion o 555 people
pe yea p esen ing wi h HBP in he ACS popula ion
(Table 2).
Figu e 3displays he equency o ACS and s oke
admissions om 2002 o 2016. A o al o 115 public
hospi als om mainland Po ugal egis e ed ACS ad-
missions om2002 o2016and122 egis e eds oke
admissions. A maximum age o 99 yea s old was ound
in he da abase and he majo i y o admissions we e o
bo h ACS and s oke.
We analysed ends o ACS and s oke and es ed he
signi icance o a b eakpoin in he yea 2013.
Table 1 Demog aphic cha ac e iza ion o he da a analysed
ACS (DRG da a) S oke (DRG da a) HBP in ACS pa ien s
(NRACS da a)
Be o e egula ion
Female % 26,00% 49,43% 35,33%
Age ≥65% 37,93% 77,15% 65,38%
A e egula ion
Female % 26,36% 49,61% 32,67%
Age ≥65% 37,85% 78,26% 64,29%
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 3 o 9
Al hough none o he emaining ends we e signi ican
(Table 2) o ACS c ude a es (β=−0.057, CI: - 0.154,
0.039) and s oke c ude a e (β=−0.049, CI: -0.128,
0.029), a dec easing end can be obse ed.
When u he s a i ied da a by sex and age, al hough
no signi ican ends we e obse ed, a dec easing end o
ACS was ound in women bu no in men. The la ges
dec ease was ound o people o e 65 yea s old o
bo h ou comes. Ne e heless, all hese esul s should be
in e p e ed wi h cau ion as none o he coe icien s
we e signi ican (p- alues > 5%), and ze o was always
included in he con idence in e al.
The seasonal pa e n obse ed o ACS and s oke was
consis en wi h ha epo ed elsewhe e [21], wi h highe
a es o admission o e win e , and lowe a es du ing
he summe (Fig. 3).
Discussion
Ou esul s showed inc easing ends in he p opo ion
o HBP como bidi y in he ACS popula ion un il 2013,
he ollowing yea s he ends appea o dec ease. This
yea was used as a b eakpoin o es o di e ences in
ends o ACS and s oke. Dec easing ends o bo h
ou comes we e also ound, bu we e no signi ican .
Al hough ou esul s we e no s a is ically signi ican ,
and hus mus be in e p e ed wi h cau ion, i is encou -
aging o ind dec easing ends, especially in he p opo ion
o HBP pa ien s in he ACS popula ion, wi h a educ ion o
nea ly 600 people pe yea , a e he implemen a ion o a
majo public heal h measu e ha was mean o educe sal
in ake.
E en a small educ ion in he p opo ion o HBP in
he ACS popula ion, as he one obse ed in ou s udy
Fig. 1 P opo ion o pa ien s wi h HBP in he ACS popula ion. Female/male a io om yea s 2002 o 2015
Fig. 2 T ends in o e all mon hly p opo ion o HBP in ACS pa ien s om Janua y 2002 o Decembe 2015. Dashed line ep esen s he beginning
o 2013, yea associa ed o he es ima ed decline in ends
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 4 o 9
Table 2 Resul s om he h ee eg essions applied, segmen ed mul iple linea eg ession model, o he p opo ion o HBP pa ien s,
and bo h mul iples linea eg essions using s anda d me hods o in e up ed ime se ies, o he ACS and s oke ou comes
β(CI) - alue p- alue
HBP p opo ion
O e all
a
P e-b eakpoin end (change pe mon h) 0.004 (0.003;0.006) ––
Change in end (pos -b eakpoin s p e-b eakpoin ) −0.006 –< 0.001
Pos -b eakpoin end (change pe mon h) −0.002 (−0.003;-0.001) ––
Male
a
P e-b eakpoin end (change pe mon h) −0.003(−0.022;0.022) ––
Change in end (pos -b eakpoin s p e-b eakpoin ) −0.016 –0.215
Pos -b eakpoin end (change pe mon h) −0.019(−0.061;0.023) ––
Female
a
P e-b eakpoin end (change pe mon h) −0.003(−0.028;0.022) ––
Change in end (pos -b eakpoin s p e-b eakpoin ) −0.016 –0.215
Pos -b eakpoin end (change pe mon h) −0.018(−0.052;0.014) ––
Age < 65
a
P e-b eakpoin end (change pe mon h) −0.022(−0.798;0.754) ––
Change in end (pos -b eakpoin s p e-b eakpoin ) 0.011 –> 0.05
Pos -b eakpoin end (change pe mon h) −0.011(−0.039;0.017) ––
Age ≥65
a
P e-b eakpoin end (change pe mon h) 0.029(−0.017;0.075) ––
Change in end (pos -b eakpoin s p e-b eakpoin ) −0.018 –> 0.05
Pos -b eakpoin end (change pe mon h) 0.011(−0.017;0.039) ––
ACS c ude a es (pe 100,000 adul s)
O e all
a
Time o he b eakpoin −0.112(−2.041;1.817) −0.114 0.909
Time o he b eakpoin
a
ime in e ac ion −0.031(−0.09;0.036) −0.903 0.368
Male
a
Time o he b eakpoin 0.289(−2.269;2.848) 0.222 0.825
Time o he b eakpoin
a
ime in e ac ion −0.018(−0.108;0.072) −0.393 0.695
Female
a
Time o he b eakpoin −0.497(−1.927;0.932) −0.682 0.496
Time o he b eakpoin
a
ime in e ac ion 0.013(−0.034;0.060) 0.560 0.576
Age < 65
a
Time o he b eakpoin 0.151(−0.723;1.024) 0.338 0.736
Time o he b eakpoin
a
ime in e ac ion −0.015(−0.044;0.015) −0.986 0.325
Age ≥65
a
Time o he b eakpoin 0.151(−5.159;6.721) 0.258 0.7970
Time o he b eakpoin
a
ime in e ac ion −0.015(−0.358;0.066) −1.349 0.1792
S oke c ude a es (pe 100,000 adul s)
O e all
a
Time o he b eakpoin 0.265(−1.399;1.929) 0.312 0.755
Time o he b eakpoin
a
ime in e ac ion −0.037(−0.091;0.016) −1.370 0.172
Male
a
Time o he b eakpoin 0.900(−0.743;2.543) 1.074 0.284
Time o he b eakpoin
a
ime in e ac ion −0.022(−0.074;0.030) −0.822 0.412
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 5 o 9

o 555 pe sons pe yea achie ed h ough a popula ion-wide
app oach, can ha e huge impac s [22,23]. This impac s has
e ec i ely slowed down he de elopmen o a he oscle osis
in young people, he eby educing he likelihood o u u e
epidemics o CVD [24].
The dec easing end o ACS was obse ed o women
bu no in men, in ac sal in ake ha e been p e iously
link o highe isk o CV e en s in women bu no in men
[25], mo e pa icula ly s udies ha e ound ha women
could bene i mo e, conce ning s oke educ ion, om
die a y sal educ ion han men [26].
As sal sensi i i y is known o be g ea e in he elde ly
we hypo hesized ha i he sal educ ion law could ha e
some e ec i would be g ea e o he elde ly [27,28]. In
ac ou esul s sugges a dec easing end o all ou comes
in he olde g oup.
Table 2 Resul s om he h ee eg essions applied, segmen ed mul iple linea eg ession model, o he p opo ion o HBP pa ien s,
and bo h mul iples linea eg essions using s anda d me hods o in e up ed ime se ies, o he ACS and s oke ou comes
(Con inued)
β(CI) - alue p- alue
Female
a
Time o he b eakpoin 0.999(−1.204;3.202) 0.888 0.376
Time o he b eakpoin
a
ime in e ac ion −0.047(−0.121;0.027) −1.244 0.215
Age < 65
a
Time o he b eakpoin 0.448(−0.261;1.157) 1.238 0.217
Time o he b eakpoin
a
ime in e ac ion −0.014(−0.037;0.009) −1.207 0.229
Age ≥65
a
Time o he b eakpoin 2.548(−5.351;10.446) 0.632 0.528
Time o he b eakpoin
a
ime in e ac ion −0.238(−0.502;0.026) −1.764 0.079
Values no p esen ed in he able (−) a e no a ailable o he ype o eg ession
β ep esen s he coe icien s in he eg ession
HBP High blood p essu e, ACS Acu e co ona y synd ome, CI con idence in e al
a
All models we e adjus ed o seasonali y
Fig. 3 T ends in o e all mon hly c ude a es o CV admissions om Janua y 2002 o Decembe 2016 pe 100,000 adul s. a) T ends o s oke
c ude a es admissions. b) T ends o ACS c ude a es admissions. Dashed lines ep esen he beginning o 2013, yea associa ed o he es ima ed
decline in ends
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 6 o 9
Resul s om his ype o popula ion-wide app oach
we e seen in he UK, whe e sal educ ion campaigns
showed signi ican esul s, achie ing a 15% sal educ ion
om 2003 o 2011, which ansla ed in o abou 6000
ewe dea hs om CVD, sa ing abou 1.5 billion pounds a
yea [8].
The dec easing ends o all o ou ou comes was no as
g ea as we expec ed, howe e he ac ha he s a ing o
he dec ease akes place a e he implemen a ion o hese
app oaches, and he end o HBP in ACS pa ien s was
s eadily inc easing be o e ha , suppo s ou hypo hesis
ha his app oach o educing sal in b ead and making
p e-packed sal labelling manda o y can in luence HBP
p e alence in ACS pa ien s as well as CVD ends.
The ac ha , sal in ake le els ha e been dec easing in
Po ugal o he mos ecen alue o 7.3 g/day in 2016
[14] also suppo s ou hypo hesis o he po en ially e ec
o he egula ion applied in he coun y. Al hough his
alue was ob ained by a 24 h die a y ecall ques ion-
nai e [29], hese alues we e alida ed agains u ina y so-
dium exc e ion o a sub-sample o 100 subjec s and he
alues we e highly co ela ed.
In addi ion, BP le els ha e been declining in he
Po uguese popula ion, om a mean BP o 134.7/
80.5 mmHg in 2003 [30] o a mean BP o 127/
74.6 mmHg in 2012 [10].
Fu he mo e, se e al s udies showed ha b ead is one
impo an sou ce o sal in Po ugal [7], and con ibu es
o abou one-six h o daily sal in ake [7]. Resul s om he
Na ional Food, Nu i ion and Physical Ac i i y Su ey
sugges mos o he sal consumed by he popula ion
comes di ec ly om b ead and oas , cha cu e ie p oduc s,
and soups [14]. I was all his e idence ha led o he
c ea ion o he egula ion o educe sal in b ead o a
minimum o 1.4 g o sal pe 100 g o inal p oduc [31]
and manda o y labelling o p e-packed p oduc s s a ing
clea ly he sal con en o he p oduc . Po ugal was, hus,
he i s wes e n coun y o c ea e a law o he clea
de ini ion o he quan i y o sal con ained in b ead.
Besides he legisla ion in 2010, se e al ini ia i es ha e
been ca ied in Po ugal o educe sal in ake, such as:
elec onic ools, such as websi es included in he Na ional
P og am o he P omo ion o Heal hy Ea ing, o ee
dis ibu ion o books and b ochu es, by he c ea ion o
an anima ed se ies, and he c ea ion o he Na ional
Food, Nu i ion and Physical Ac i i y Su ey, aiming o
collec na ionwide da a on die a y in ake and physical
ac i i y [14].
The e is al eady e idence ha educing sal in ake could
educe BP in he Po uguese popula ion. One communi y
in e en ion ial conduc ed in Po ugal demons a ed
ha educing sal in ake in an en i e illage, including
cooking and p ocessed ood, led o a signi ican educ ion
in he BP o he popula ion [32].
Policy in e en ions o educe na ional sodium con-
sump ion ha e demons a ed o be highly cos e ec i e in
nea ly e e y coun y in he wo ld. These in e en ions
could educe millions o disabili y adjus ed li e yea s a
low cos and be mo e cos -e ec i e han pha macological
in e en ions [26,33].
Policy and sys em changes a e c i ical o educe HBP in
popula ions, including legisla ion and public educa ion
o educe die a y sodium and ood p icing policies, o
suppo p e en ion and managemen o CVD [34].
Al e na i e public heal h app oaches, such as educing
sal in p ocessed oods and b ead, and labelling o p ocessed
ood along wi h he use o mul iple iscal and educa ional
policies, ha e al eady been p oposed by he WHO as he
i s -line app oach o CVD educ ion, when implemen ed
onawidescale[24,34].
In spi e o se e al e o s being made in he coun y o
educe sal in ake, he e is s ill oom o imp o emen ,
namely in ood labelling [35], adjus ing i o he le el o
heal h li e acy in he coun y. Once he le el o heal h
li e acy in Po ugal was sligh ly lowe han he es o
Eu opean coun ies [36], his migh ha e p e en ed he
popula ion om ully bene i ing om he labelling, as
he in e p e a ion o sal con en in each ood can be
di icul .
Simple labelling sys ems al eady exis in o he coun ies,
such as labels ha ely on he use o on -o -pack in o ma-
ion such as logos wi h in o ma ion on he o e all heal hi-
ness o he ood and a ic ligh and colou coding sys ems,
which migh help ci izens make heal hie choices. Coun ies
such as Finland and he UK ha e al eady implemen ed
some o hese labelling sys ems. In Finland, ood p oduc s
wi h sal con en s below he designa ed le els display a
low-sal label o emphasise hei lowe - han-con en ional
sal le els [37]. In he UK, a a ic ligh sys em o dis in-
guish be ween high, medium, and low sal con en in ood
p oduc s was implemen ed. These s a egies p o ed o be
e icien in educing sal in ake in he popula ion [38]. The
a ic ligh labelling sys em has been p oposed by he Po -
uguese Hype ension Socie y o help he popula ion choose
p oduc s ega dless o hei le el o li e acy.
Mo e es ic ions a e being planned in Po ugal o u -
he educe sal in ake, such as a axes on p oduc s wi h
mo e han 1 g o sal pe 100 g o inished p oduc such as:
p e-packaged c acke s and biscui s; p e-packaged ce eal
lakes and p essed ce eals; and p e-packaged, dehyd a ed
po a o chips. A a e o 0.80 Eu os pe kilog am o inished
p oduc will be applied o hese p oduc s.
On he o he hand, u he educ ion o sal con en in
b ead, o a minimum o 1 g pe 100 g o inal p oduc ,
was p oposed o be achie ed by 2020, wi h con inuous
educ ions each yea a e 2018.
Ou s udy p esen s encou aging indica ions sugges -
ing he e ha e been educ ions in he p opo ion o
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 7 o 9
hype ensi es among ACS pa ien s a e 2013, along
wi h an annual dec ease in he a es o ACS and s oke.
Limi a ions
Howe e , we ecognise some limi a ions o he s udy.
Like any ecological s udy, i is no possible o p o e
causal ela ions, i.e. di ec associa ion be ween he ini ia-
i es o educe sal implemen in he coun y he educ ion
obse ed in he p opo ion o hype ensi es ACS pa ien s.
Howe e , ou me hodology was applied, using he same
da a o analyse he e ec s o he smoking ban legisla ion
on ACS ends, and a signi ican educ ion was ound igh
a e he ban [39].
On he o he hand, i migh be oo soon o no ice
g ea e ec s om sal educ ion on CVD ends.
The ac ha un il 2013, he end o he p opo ion
o hype ensi es was con inuously inc easing, and igh
a e 2013 a dec ease in end can be obse ed, sugges s
ha he lack o s a is ical signi icance could esul om
he ime pe iod being analysed being oo sho o cap u e
u he educ ions.
Mo eo e , ou s udy has some s eng hs, such as he ac
ha we used wo well alida ed and s anda dised da abases
is a majo s eng h as his allows o an easy compa ison
wi h o he in e na ional s udies mainly hose de eloped in
o he Eu opean coun ies. As well as he a ailabili y o
in o ma ion on gende and age, his allowed us o assess
he obus ness o ou indings among di e en subg oups.
Also he ime se ies me hod is p e e ed o e he simple
p e- and pos -p opo ion compa ison me hod ha does
no ake he p e-in e en ion end in o accoun , and also
allows co ec ion o au oco ela ion [40].
Conclusions
In conclusion, he ac ha we ound dec easing ends
o bo h HBP in ACS pa ien s and CVD ou comes a e
majo ini ia i es o educe sal in ake we e implemen ed
in he coun y, sugges s ha his ype o app oaches,
al hough ha d o measu e, can impac he ends o majo
public heal h ou comes. Thus, his esea ch is ele an o
he public heal h communi y because i p o ides an
indica ion abou he impac ha a popula ion-wide
app oaches can ha e on CVD isk ac o s, and CVD ends
hemsel es. Ou esul s sugges ha popula ion-wide
app oaches can ha e an impac on he p e en ion and
imp o emen o CVD con ol, educing he numbe o
CVD e en s and e en ually educing p ema u e dea h,
mo bidi y, and disabili y by CVD. Ou s udy also highligh s
he impo ance o measu ing he impac o hese ypes o
ini ia i es. These indings s ess he need o public heal h
policy in CVD o imp o e he heal h o popula ions
add essing, in he i s place, he well iden i ied isk ac o s
o CVD.
Undoub edly, mo e s udies a e needed o assess he
impac o such measu es, no only o o he diseases beside
CVD, bu also adding mo e yea s o he s udy would allow
analysis o long e ms e ec s o he public heal h ini ia-
i es. On he o he hand, as mo e es ic ions on sal in ake
a e being planned in Po ugal, in he nex yea s i is e y
ele an o assess wha is he cu en pano ama and wha
u he educ ions we can expec .
Abb e ia ions
ACS: Acu e Co ona y Synd ome; BP: Blood p essu e; CI: Con idence in e al;
CVD: Ca dio ascula disease; DRG: Diagnosis ela ed g oup; HBP: High blood
p essu e; NRACS: Na ional Regis y o Acu e Co ona y Synd ome
Acknowledgemen s
The au ho s hank he in es iga o s o he Na ional Regis y o Acu e
Co ona y Synd ome, Sociedade Po uguesa de Ca diologia.
This esea ch did no ecei e any speci ic g an om unding agencies in he
public, comme cial, o no - o -p o i sec o s.
A ailabili y o da a and ma e ials
The da a ha suppo he indings o his s udy a e a ailable om he
Minis e o Heal h O ice, (email: [email p o ec ed]) o he DRG da a.
Da a om he Na ional Regis y o ACS can be eques ed om he
Po uguese Socie y o Ca diology (sand a.co[email p o ec ed]). Howe e
es ic ions apply o he a ailabili y o hese da a, which we e used unde
license o he cu en s udy, and so a e no publicly a ailable. Da a a e
howe e a ailable om he au ho s upon easonable eques and wi h
pe mission om bo h he Minis e o Heal h O ice and he Po uguese
Socie y o Ca diology.
Au ho s’con ibu ions
DA was esponsible o all s a is ical analysis and he esul s in e p e a ion, as
well as esponsible o w i ing he pape . PS was esponsible o e iew all
s a is ical analysis and esul s as well as o scien i ic inpu . CMD was
in ol ed in d a ing he manusc ip as well as he inal e ision o he s udy.
FP was esponsible o scien i ic inpu and inal e ision o he s udy. All
au ho s ead and app o ed he inal manusc ip .
E hics app o al and consen o pa icipa e
App o al o access da a was ob ained p e iously om he Minis e o Heal h
O ice and he Po uguese Socie y o Ca diology. E hics app o al and
consen o pa icipa e a e no applicable o his s udy.
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Au ho de ails
1
Escola Nacional de Saúde Pública, Uni e sidade No a de Lisboa, A enida
Pad e C uz, 1600-560 Lisboa, Po ugal.
2
Cen o de In es igação em Saúde
Pública - ENSP-UNL, A enida Pad e C uz, 1600-560 Lisboa, Po ugal.
3
Depa men o Epidemiology o he Ins i u o Nacional de Saúde Dou o
Rica do Jo ge, A enida Pad e C uz, 1649-016 Lisboa, Po ugal.
4
Se iço de
Ca diologia, Hospi al de San a Ma ia, Cen o Hospi ala Lisboa No e - EPE,
Cen o, Académico Medicina de Lisboa, Lisbon, Po ugal.
5
Cen o
Ca dio ascula da Uni e sidade de Lisboa, A . P o . Egas Moniz, 1649-035
Lisboa, Po ugal.
Ab eu e al. BMC Public Heal h (2018) 18:722 Page 8 o 9
Recei ed: 8 Decembe 2017 Accep ed: 29 May 2018
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