Population strategies to reduce sodium intake and cardiovascular diseases in the United States: Applying RE-AIM to policy implementation

Cardiovascular disease (CVD) deaths in the United States approached 1 million in 2019, accounting for 33% of annual mortality. Americans consume 3,400 mg of sodium per day, nearly 50% higher than the limit recommended by the U.S. FDA and WHO. Population sodium reduction is a strategy to reduce CVD deaths. The WHO recommends four ‘best buys’ for sodium reduction: product reformulation, front-of-package labeling, institutional procurement, and public educational campaigns. The FDA set a goal in 2016 to reduce sodium consumption to 2,300 mg per day within ten years. Unfortunately, a lag exists in sodium policy implementation in the U.S. An urgent need exists to apply implementation science to reduce excessive sodium consumption to ultimately reduce CVD deaths. My research responds to this need by applying the RE-AIM framework to policy implementation in systematically assessing sodium policy reach, effectiveness, adoption, implementation, and maintenance. My preliminary studies in global CVD modeling and U.S. multisectoral policy implementation serve as a critical foundation in formulating the overall objective for the proposed research and in establishing study feasibility of carrying out this research. The rationale for this research is to provide policy makers with the information and tools they need to improve cardiovascular health. This study will analyze historical state-level data to estimate what ‘has been’ adopted, model to learn what ‘might be’ the health gain and its distribution in nationwide implementation, and conduct qualitative study about what ‘could be’ implemented. I analyze retrospective data on sodium policy adoption, maintenance, and reach in the United States from 2000 to 2022 (Aim 1). I model how many lives might be saved by implementing institutional procurement policy in all states in ten years (Aim 2). I assess capacity and constraints in multilevel implementation system and stakeholder’s conventional and active roles in qualitative study (Aim 3). Outcomes of this study include: (a) scientific evidence about current sodium policy implementation RE-AIM measures; (b) an interactive tool, Policy RE-AIM, to present the findings from the three Aims in lay language and through visualization; and (c) preliminary data to apply for future funding (e.g., an R01 award) to advance CVD policy modeling methods and to improve sodium policy implementation at the county level. The proposed research illustrates a novel application of RE-AIM to policy implementation science. It is innovative in developing an interactive tool that can be used in the future as part of a strategy to improve policy implementation to ultimately eliminate preventable cardiovascular health disparities. The intended impact of my study is to contribute to the application of policy IS to CVD prevention and accelerate the translation of cardiovascular science into real-world improvements in health equity. I have multidisciplinary mentorship with expertise in implementation science (Dr. Bryan Weiner), policy implementation (Dr. Jodi Sandfort), modeling (Dr. Yan Li), cardiovascular health (Dr. Chris Longenecker), as well as sodium and health (Dr. David Watkins).