Public health workers move ahead to reduce salt intake: IoM: FDA should act on sodium levels
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* Kim Krisberg

The movement to cut down on salt in the food supply is inching its way around the globe, and while the U.S. food industry is slowly making its own voluntary progress, advocates continue to call for strong federal action.

From Canada to Finland to Australia, governments have been tackling the problem of too much salt and its tie to life-threatening diseases. Finland began its efforts four decades ago and most recently instituted new labeling requirements for heavily salted foods. This year, Australian health officials worked with the food industry to set salt reduction targets for cereals, breads and other baked goods. Canadian health authorities are developing a population-wide strategy for reducing sodium consumption, and in 2008, health officials in the United Kingdom reported a successful drop in average sodium intake just a handful of years after the U.K. began its own aggressive salt campaign.

Such efforts provide a good template to help the United States embark on its own salt reduction journey, say public health advocates. A recent report from the Institute of Medicine issued a similar call to action, concluding that the current patchwork of voluntary U.S. efforts will not stem the nation’s dangerous tide of hypertension and cardiovascular disease rates.

The IoM report, which was released in April and completed at the request of Congress, said reducing Americans’ sodium consumption will require the federal government take a lead role, setting new standards for food manufacturers, restaurants and food service companies.

“For 40 years, we have known about the relationship between sodium and the development of hypertension and other life-threatening diseases, but we have had virtually no success in cutting back the salt in our diets,” said Jane Henney, MD, chair of the IoM report’s authoring committee and a professor of medicine at the University of Cincinnati.

In response to the report, FDA said it will “thoroughly review the recommendations” and build plans for how the agency can work to reduce sodium in the food supply. FDA also said the U.S. Department of Health and Human Services will establish an interagency working group focused on sodium. However, FDA pointedly noted that it has not made a decision to regulate sodium “at this time.”

A wealth of scientific evidence supports efforts to cut salt intake. A study published in a February issue of the *New England Journal of Medicine* found that reducing dietary salt by 3 grams per day population-wide could reduce the yearly number of new U.S. cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000, and heart attack by 54,000 to 99,000. Such a sodium reduction could also save up to $24 billion in health care costs every year, the study found. An April editorial published in the *Annals of Internal Medicine* and co-authored by Centers for Disease Control and Prevention Director Thomas Frieden, MD, MPH, noted that “after tobacco control, the most cost-effective intervention to control chronic diseases might be reduction of sodium intake.”

“Reducing sodium intake is a relatively low-cost, high-return public health strategy,” Darwin Labarthe, MD, PhD, director of CDC’s Division for Heart Disease and Stroke Prevention, told *The Nation’s Health*. “Public information and awareness of sodium intake is important, but far from sufficient to have the needed impact. This is largely because people have such little choice with respect to their sodium content. So, the necessity is to go beyond that…the food environment must change.”

The IoM report recommends FDA should modify salt’s present status as “generally recognized as safe,” which would change how much sodium and sodium-containing compounds could be added to processed foods. Currently, the average American takes in about 3,400 milligrams of salt daily. The federal Dietary Guidelines for Americans recommends a daily maximum of no more than 2,300 milligrams, though only 1,500 milligrams is recommended for middle-aged and older Americans, blacks and those with hypertension — three high-risk groups that make up about 70 percent of U.S. adults.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/5/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/40/5/1.3/F1)

Many dietary sources of sodium are foods not commonly thought of as being high in salt, such as cottage cheese.

Photo by Magdalena Kucova, courtesy iStockphoto

“FDA really can’t ignore this problem any more,” said longtime sodium reduction advocate Stephen Havas, MD, MPH, MS, an adjunct professor at Northwestern University’s Feinberg School of Medicine and an APHA member. “Delay comes at a huge price in terms of premature death as well as people becoming disabled by heart attacks, strokes and congestive heart failure.”

## U.K. sees results, New York City takes lead

The United Kingdom’s work to reduce salt consumption began in 2003 and has already culminated in significant positive health outcomes.

In 2008, the nation’s Food Standards Agency released urinary sodium survey results showing the average daily salt consumption had declined from 9.5 grams to 8.6 grams. According to Alette Addison, head of the Salt Reduction Strategy Team at the Food Standards Agency, the reduction translates into the prevention of 6,000 premature deaths. The U.K. campaign involves rigorous government-led sodium reduction work, including setting reduction targets, negotiating commitments from food companies, creating public awareness campaigns and monitoring health outcomes.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/5/1.3/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/40/5/1.3/F2)

A woman walks past bags of chips manufactured by PepsiCo Frito-Lay in March in Miami. PepsiCo recently announced plans to reduce the sodium in some of its products.

Photo by Joe Raedle, courtesy Getty Images

“Engaging with the food industry was and remains key,” Addison told *The Nation’s Health*. “This was the first time we had worked like this, trying out a goal-oriented partnership working in the health arena. This has been a success but requires staff time and resources to get out there and sell the program to industry.”

While many public health advocates hope for similar government action in the United States, a number of food companies, such as Kraft Foods and Heinz, have already agreed to voluntary salt reductions, thanks to the National Salt Reduction Initiative.

Launched in 2008, the initiative is led by the New York City Department of Health and Mental Hygiene and includes dozens of partners nationwide, from state and local health departments to national health organizations, such as APHA. Earlier this year, the initiative debuted proposed targets to guide the voluntary reductions, with a goal of cutting salt in packaged and restaurant food by 25 percent over five years — a goal that would reduce national salt intake by 20 percent. Working with the food industry, the initiative created specific targets for 61 categories of packaged foods and 25 classes of restaurant foods. The majority of sodium consumed by Americans is in processed and packaged foods and is not added at the table.

“Industry, by and large, recognized how important it is to reduce sodium,” said Sonia Angell, MD, MPH, director of the Bureau of Chronic Disease Prevention at the New York City health department. “What we realized is that commitments made by individual companies won’t get to the level to save lives. That’s why a public-private partnership is key: It provides the framework to join together and move in an organized fashion.”

At the federal level, CDC’s Labarthe said the agency has been working in anticipation of the IoM report, including work with fellow federal agencies to expand surveillance capacity to track sodium levels and resulting health outcomes. CDC also convened a public health law summit on sodium reduction in June to help states and localities take action.

“We recognize…that sodium alone is not the only area where our dietary habits need improvement,” Labarthe said. “But there is enough potential for sodium reduction to have major health impacts that the gains we expect can be achieved regardless of the needed progress in other areas.”

For more on salt and health, visit [www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml](http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml). For a copy of the IoM report, “Strategies to Reduce Sodium Intake in the United States,” visit [www.iom.edu](http://www.iom.edu). To watch a webinar sponsored by APHA, CDC and IoM on “Strategies to Reduce Sodium Intake in the U.S.,” visit [www.apha.org/advocacy/reports](http://www.apha.org/advocacy/reports).

*   Copyright The Nation’s Health, American Public Health Association