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Strategies to Reduce Sodium Intake in the United States
Appendix B
Government Initiatives and Past Recommendations of the National Academies, the World Health Organization, and Other Health Professional Organizations
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TABLE B-1 Government Initiatives
Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
White House Conference
1969
Conference on Food, Nutrition, and Health: Final Report (White House Conference, 1969)
Provided advice on the desirability of reducing sodium intake
Hypertensive individuals
Encouraged food processors to minimize the amount of salt in processed foods
Food processors
Identified a need for food labeling of sodium
U.S. Senate—Select Committee on Nutrition and Human Needs
1977
Dietary Goals for the United States, 2nd edition (Select Committee on Nutrition and Human Needs, 1977)
Decrease salt intake to about 5 g/d
All Americans
U.S. Department of Health and Human Services—Centers for Disease Control and Prevention (CDC)
2009
The Congressional Omnibus Appropriations Acta (2009) included language encouraging CDC to work with major food manufacturers and chain restaurants to reduce sodium content in their products and to submit to the Committee on Appropriations and the House of Representatives and the Senate an evaluation of its sodium-reduction activities within 15 months of enactment of the act, and annually thereafter
CDC plans to explore existing national and international public and private initiatives to reduce sodium in the food supply
In fiscal years 2009–2010, CDC plans to convene public and private stakeholders to build relationships and partnerships to investigate approaches for reducing sodium consumption
CDC will explore knowledge gaps, utilizing its data systems to analyze and release pertinent sodium related data (CDC, 2009)
Food manufacturers and chain restaurants
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U.S. Department of Health and Human Services—Surgeon General
1979
Healthy People: Surgeon General’s Report on Health Promotion and Disease Prevention (Public Health Service, 1979)
Consume less salt; cook with only small amounts of salt, avoid adding salt at the table, avoid salty prepared foods
All Americans
1988
Surgeon General’s Report on Nutrition and Health (Public Health Service, 1988)
Reduce intake of sodium by choosing foods relatively low in sodium and limiting the amount of salt added in food preparation and at the table
All Americans
U.S. Department of Health and Human Services—Public Health Service
1980
Promoting Health and Preventing Disease: Objectives for the Nation (Public Health Service, 1980)
By 1990:
Reduce the average daily sodium ingestion (as measured by excretion) for adults to at least the 3,000–6,000 mg range
> 75% of the population should be able to identify the principal dietary factors for high blood pressure and three other diseases
70% of adults should be able to identify the major foods that are low in sodium
Sodium in processed foods should be reduced by 20% from present levels
All Americans
1990
Healthy People 2000 (NCHS, 2001)
Increase % of persons preparing foods without adding salt from 43% (baseline) to a target of 65%
Increase % of persons rarely or never using salt at the table from 60% (baseline) to 80%
Increase % of persons regularly purchasing foods with reduced salt and sodium content from 20 (baseline) to 40%
All Americans
2001
Healthy People 2000 Review (NCHS, 2001)
During the mid-1990s, overall the percent of persons rarely or never using salt at the table ranged from 56–62%, and the % of persons regularly purchasing foods with reduced salt and sodium content was 19%
All Americans
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
2000
Healthy People 2010 (HHS, 2000)
Increase the percentage of persons who consume ≤ 2,400 mg/d sodium from baseline (21% based on the National Health and Nutrition Examination Survey [NHANES] 1988–1994) to 65% (only 13% met target in 2003–2004 [Public Health Service, 2008])
Persons 2 or more years of age
U.S. Department of Health and Human Services—National Heart, Lung, and Blood Institute (NHLBI), the National Institutes of Health
1972
National High Blood Pressure Education Program (NHLBI, 2010)
Cooperative effort among professional and voluntary health agencies, state health departments, and many community groups with the goal to reduce death and disability related to high blood pressure through programs of professional, patient, and public education
All Americans
1993
Working Group Report on Primary Prevention of Hypertension (National High Blood Pressure Education Program) (Whelton et al., 1993)
Reduce salt intake to no more than 6 g per day
All Americans
1995, 1999
Statement from the National High Blood Pressure Education Program Coordinating Committee (NHLBI, 1999)
Moderate salt and sodium intake
Establish 2,400 mg/d sodium as a national dietary goal
1996
Workshop: Implementing Recommendations for Dietary Salt Reduction: Where Are We? Where Are We Going? How Do We Get There? (NHLBI, 1996)
Develop public and professional education activities within the primary prevention campaign to convey the rationale for and benefits of lowering dietary salt/sodium for hypertension prevention to the appropriate target audiences
The salt/sodium messages must be consistent with and often integrated into overall healthful lifestyle diet messages, such as the Dietary Guidelines, USDA Food Guide Pyramid, and FDA food labels
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Experiences with intervention studies should be transferred to clinical and/or community settings after reviewing or evaluating and adapting, if necessary, strategies, methods, and materials
Gradual “silent” or “transparent” lowering of salt or sodium in the food supply will need to occur along with the opportunity for effective marketing strategies and the promotion of reduced-sodium as well as low-sodium, low-salt, and no-salt food products. These recommendations are applicable to the food production industry, as well as restaurant, catering, and foodservice industries
Data from completed clinical trials should be analyzed for the adequacy of simpler methods (e.g., casual urine collections, chloride titrator strips) as measures of sodium intake and for the validity of dietary recalls in order to consider the best feasible methods for individual and national-level assessments of sodium intake
Other research needs identified in the areas of food technology; basic mechanisms of salt taste; and knowledge, attitudes, and skills of the public
1997
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NHLBI, 1997)
Reduce sodium intake to ≤ 100 mmol/d (2,400 mg sodium or 6 g sodium chloride)
2002
National High Blood Pressure Education Program (update of 1993 report) (NHLBI, 2002)
Reduce dietary sodium intake to no more than 100 mmol/d (approximately 2,400 mg of sodium or 6 g of sodium chloride)
All Americans
2003
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (NHLBI, 2004)
Reduce sodium intake to no more than 100 mmol/d (2,400 mg sodium or 6 g sodium chloride)
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Date
Program/Initiative/Report
Title Recommendations/Initiatives/Actions
Target Population (if specified)
2005
Prevent and Control America’s High Blood Pressure: Mission Possible (NHLBI with CDC and the American Heart Association [AHA] as supporting partners; 22 states participated) (NHLBI, 2005)
Promoted awareness and education materials to help the public health community attract new partners and revitalize relationships with existing partners to fight high blood pressure
Persons at high risk for hypertension
States distributed materials to public health departments; hospitals and clinics; schools; senior centers; refugee centers; faith-based organizations; work sites; primary care practices; emergency medical service groups; state health benefit plans; and disease-related organizations, such as diabetes, kidney failure, and cancer groups
Low-SES (socioeconomic status) and minority populations
2006
NIH Radio (NIH, 2006)
Produced a broadcast-ready public service announcement about fighting high blood pressure through diet
All Americans
U.S. Department of Agriculture and U.S. Department of Health and Human Services (USDA/HHS)
1980
Dietary Guidelines for Americans (USDA/HHS, 1980)
Avoid too much sodium
“Most Americans”
1985
Dietary Guidelines for Americans (USDA/HHS, 1985)
Avoid too much sodium
“Most Americans … those who are already healthy”
1990
Dietary Guidelines for Americans (USDA/HHS, 1990)
Use salt and sodium only in moderation
Healthy Americans 2 or more years of age
1995
Dietary Guidelines for Americans (USDA/HHS, 1995)
Choose a diet moderate in salt and sodium. “The Nutrition Facts Label lists A Daily Value of 2,400 mg”
Healthy Americans 2 or more years of age
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2000
Dietary Guidelines for Americans (USDA/HHS, 2000)
Choose and prepare foods with less salt
Healthy Americans 2 or more years of age
2005
Dietary Guidelines for Americans (USDA/HHS, 2005)
Consume < 2,300 mg/d of sodium (~1 tsp salt)
Choose and prepare foods with little salt, and consume potassium-rich foods, such as fruits and vegetables
Americans 2 or more years of age
Individuals with hypertension, African Americans, and middle-aged and older adults: Aim to consume no more than 1,500 mg/d of sodium, and meet the potassium recommendation (4,700 mg/d) with food
High-risk populations
2010
Dietary Guidelines for Americans
Convened expert Advisory Committee to update the Dietary Guidelines for Americans for the year 2010. Sodium intake is included as a topic area for discussion (results pending)
U.S. Food and Drug Administration (FDA)
1973
Food labeling (HHS/FDA, 1973)
Required specific format when a nutrition claim was made in labeling or advertising or when a nutrient was added to a food
Better information about the sodium content of foods was an early focus
1979
Evaluation of the health aspects of sodium chloride and potassium chloride as food ingredients (SCOGS, 1979)
Consumption of sodium chloride should be reduced
Guidelines should be developed for restricting salt in processed foods
The sodium content of processed foods should be labeled
1981
Initiative with NHLBI (Derby and Fein, 1995)
Educate the public about sodium
Encourage manufacturers to display the sodium content on food labels
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
1982
Rejected petitions requesting reclassification of salt’s status from “GRAS” (generally recognized as safe) to “food additive” and the addition of warning labels to highsodium foods and salt packets by deferring action on GRAS status of salt (HHS/FDA, 1982)
Deferred action pending assessment of the impact of
Sodium labeling regulations
Manufacturer efforts to voluntarily reduce salt
Indicated that a voluntary program would produce the desired results with less regulatory burden and affirmed that the food industry was in the best position to reduce sodium levels in processed foods and should be given a chance to do so
1984
Sodium labeling (HHS/FDA, 1984)
Sodium added to mandatory list of nutrients to be declared on food labels
Defined the terms for sodium content claims
1993–2005
Nutrition Labeling Final Rules (HHS/FDA, 1993a,b,c, 1994, 2005)
Established a Daily Value (DV) of 2,400 mg for sodium labeling
Mandated declaration of sodium content on all foods (mg and % DV)
Established labeling rules:
Nutrient content claims for “free” (< 5 mg sodium per serving), “low” (≤ 140 mg sodium per serving), and “reduced or less than” (≥ 25% less sodium per serving than an appropriate reference food)
Foods labeled as “healthy” to contain ≤ 480 mg sodium per serving until Jan. 1, 1998, at which time sodium levels were to decrease to ≤ 360 mg per serving
Health claim: “Diets low in sodium may reduce the risk of high blood pressure” (foods ≤ 140 mg per serving)
Disqualifying or disclosure levels (≤ 480 mg per serving)
2005
Final rule regarding sodium levels in foods labeled as “healthy” (HHS/FDA, 2005)
Retained 1993 level of ≤ 480 mg sodium per serving; eliminated requirement that this level drop to ≤ 360 mg
Rationale:
Technological barriers to reducing sodium in processed foods
Poor sales of products meeting lower-sodium levels
More restrictive sodium levels would inhibit the development of new “healthy” food products
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2007
Public hearing in response to a 2005 petition (CSPI, 2005) requesting rulemaking regarding salt and a House of Representatives’ Committee on Appropriations 2005 statement encouraging the agency to focus on ways—both voluntary by the food industry and regulatory by FDA and USDA—to reduce salt in processed and restaurant foods (HHS/FDA, 2007a)
The petition specifically requested FDA to
revoke the GRAS status of salt
amend any prior sanctions for salt
require food manufacturers to reduce the amount of sodium in all processed foods
require health messages on retail packages of salt (0.5 oz.+); reduce the DV for sodium from 2,400 to 1,500 mg
Issues discussed—GRAS vs. food additive status:
Could a food additive regulation be constructed to prescribe limitations for uses of salt? If so, how?
Would reducing the salt content of food, even in a modest way, impact the safety or quality of various foods given the wide variety of technical functions for which salt is used in food? How feasible would it be to mitigate this impact, if true? Could it be mitigated by the addition of other ingredients?
If you agree that the sodium content of processed foods should be reduced, what actions (other than those suggested by the petitioner) would you recommend?
How could FDA partner with interested stakeholders regarding the development of appropriate recommendations or other information to reduce the salt content of processed foods?
Issues discussed—food labeling:
What is the effectiveness of FDA labeling regulations in reducing salt intake by the public?
What data are available regarding the potential for label statements about the health effects of salt to reduce salt intake?
To what extent could FDA’s labeling policies provide incentives to manufacturers to reduce the salt content of processed foods?
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
2007
Advanced Notice of Proposed Rulemaking (ANPR): Nutrition Labeling (HHS/FDA, 2007b)
Requested comments on questions including:
Should the Daily Reference Value (DRV) for sodium be based on the Tolerable Upper Intake Level (UL) for sodium (2,300 mg) or on the Adequate Intake (AI; 1,500 mg/d) using the population-coverage approach?
If the UL is used, should it be adjusted using the same approach (population-weighted or population-coverage) as the other Dietary Reference Intakes (DRIs)?
2007
Public Hearing (HHS/FDA, 2007c)
Discussed: use of symbols to communicate nutrition information, consideration of consumer studies and nutrition criteria
U.S. Department of Agriculture (USDA)
1993
Nutrition Labeling (USDA, 1993)
Adopted similar food labeling provisions as FDA for USDA-regulated products (notably meat and meat products)
1995
Commodity Distribution Program (provides 15–20% of school lunch program foods)
Recommended specific sodium reductions for 10 commodity food categories in USDA’s Commodity Distribution Program: canned beef, pork, poultry, luncheon meat, refried beans, salmon, tuna, ready-to-eat cereals, ham, and carrots
Excluded many other products due to the assumption that school children would find modifications unacceptable (USDA, 1995)
Children consuming school meals
2004
HealthierUS School Challenge (encourages elementary, middle, and high schools to improve the nutrition content of foods provided to children and youth) (FNS, 2010)
Rewards changes in the school nutrition environment, including providing lower-sodium foods to all children and youth:
Gold, silver, or bronze recognition: Foods with ≤ 480 mg sodium per non-entrée or ≤ 600 mg sodium per entrée
Gold award of distinction: Non-entrées with ≤ 200 mg sodium and entrées with ≤ 480 mg
Children and youth consuming school meals
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2007
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (provides vouchers to participants for the purchase of specific food items to meet nutritional needs) (USDA/FNS, 2007)
Requires that in certain food categories, foods must be lower in sodium or not have added sodium to qualify as a product that can be purchased with WIC vouchers
Low-income, nutritionally at-risk, pregnant and postpartum women; infants and children up to 5 years
2008
Commodity Distribution Program (FNS, 2008)
Plans to purchase low-sodium canned vegetables with the goal to reduce sodium levels of all canned vegetables to ≤ 140 mg per serving by school year 2010
Children consuming school meals
State and Local (Sodium Labeling Initiatives)b
2008
California
Requires restaurant chains with ≥ 20 outlets statewide to disclose sodium information at point of sale
2008
King County (Seattle)
Requires posting of sodium content on menus for restaurant chains with ≥ 15 outlets nationwide or $1 million in annual sales (collectively for the chain); if a menu board is used, nutrition information (including sodium) must be provided at point of ordering
2008
Philadelphia
Requires posting of sodium content on menus for restaurant chains with ≥ 15 outlets nationwide
2009
Montgomery County (Maryland)
Requires restaurant chains with ≥ 20 outlets nationwide to disclose sodium information (in writing) on the premises, upon request
2009
Oregon
Requires restaurant chains with ≥ 15 outlets nationwide to provide sodium information on the premises, upon request
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
Government/Non-government Organization Partnership
2009
National Salt Reduction Initiative (see Appendix G)
Partnership of over 45 cities, states, and national health organizations working to reduce U.S. population salt intake by 20% over 5 years by working with industry to set salt reduction targets that are designed to allow for gradual reductions in the sodium content of packaged and restaurant foods
U.S. population
aPublic Law 111-8, Joint Explanatory Statement: Division F—Labor, Health and Human Services, and Education, and Related Agencies Appropriations, 2009.
bImplemented or passed into law as of February 16, 2010. See Appendix J for more information.
NOTE: d = day; g = gram; mg = milligram; tsp = teaspoon.
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TABLE B-2 Past Recommendations from the National Academies and the World Health Organization
Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
The National Academies
1970
Safety and suitability of salt for use in baby foods (NRC, 1970)
Recommended ≤ 0.25% salt be added to commercial baby food
Infant food manufacturers
1980
Toward Healthful Diets (NRC, 1980a)
Use salt in moderation; adequate but safe intakes are considered to range between 3–8 g/d salt (1,200–3,200 mg/d sodium)
1980
Recommended Dietary Allowances, 9th ed. (NRC, 1980b)
Estimated Safe and Adequate Daily Dietary Intake of sodium: 1,100–3,300 mg
Adults
1989
Recommended Dietary Allowances (NRC, 1989a)
Estimated minimum requirements for sodium of 500 mg/d
Healthy persons ≥ 10 years of age
1989
Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989b)
Limit total daily intake of salt (sodium chloride) to ≤ 6 g, although ≤ 4.5 g would probably confer greater health benefits
Limit use of salt in cooking and avoid adding it to food at the table
Salty, highly processed salty, salt-preserved, and salt-pickled foods should be consumed sparingly
2005
Dietary Reference Intakes for Sodium (IOM, 2005)
Established Adequate Intake:
1.5 g/d for persons 9–50 y
1.3 g/d for persons 51–70 y
1.2 g/d for persons > 70 y
Established Upper Limit:
2.2 g/d for persons 9–13 y
2.3 g/d for persons >13 y
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
2010
Strategies to Reduce Sodium Intake (IOM, 2010)
Recommended a coordinated approach to set standards for safe levels of sodium in food using existing FDA authorities to modify the generally recognized as safe (GRAS) status of salt and other sodium-containing compounds
Recommended a nationally organized campaign to educate the public about the risks of excess sodium intake and healthful food choices, build support for government and industry activities, and support consumers in making behavior changes to reduce sodium intake
U.S. population
World Health Organization (WHO)
1990
Diet, Nutrition, and the Prevention of Chronic Diseases (WHO, 1990)
Upper limit 6 g/d salt
Lower limit not defined
2003
Diet, Nutrition, and the Prevention of Chronic Diseases (WHO, 2003)
< 5 g/d salt
NOTE: d = day; g = gram; mg = milligram; y = years.
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TABLE B-3 Past Recommendations from Health Professional Organizations
Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
American Heart Association (AHA)
1973
Diet and Coronary Heart Disease (AHA, 1973)
Moderate sodium intake
1986
Dietary Guidelines for Healthy American Adults (AHA, 1986)
Consume no more than 3,000 mg/1,000 kcal/d sodium
Adults
1988
Dietary Guidelines for Healthy American Adults (AHA, 1988)
Consume no more than 3,000 mg/d sodium
Adults
1996
Dietary Guidelines for Healthy American Adults (Krauss et al., 1996)
Consume no more than 6 g/d salt (2,400 mg/d)
Adults
1998
Dietary Electrolytes and Blood Pressure (Kotchen and McCarron, 1998)
Consume ≤ 6 g/d salt
Adults
2000
Dietary Guidelines (Krauss et al., 2000)
Limit salt intake to 6 g/d, ~100 mmol/d of sodium
General population
2006
Diet and Lifestyle Recommendations (Revision) for CVD Risk Reduction (Lichtenstein et al., 2006)
Choose and prepare foods with little salt
“In view of the available high-sodium food supply and the currently high levels of sodium consumption, a reduction in sodium intake to 1,500 mg/d (65 mmol/d) is not easily achievable at present. In the interim, an achievable recommendation is 2,300 mg/d (100 mmol/d)”
Information dissemination program
Adults and children over 2 years of age
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Date
Program/Initiative/Report Title
Recommendations/Initiatives/Actions
Target Population (if specified)
2006
Alliance for a Healthier Generation (joint initiative of AHA and the William J. Clinton Foundation) (Alliance for a Healthier Generation, 2009)
Established voluntary nutrition guidelines (based on the 2005 Dietary Guidelines and AHA’s 2006 Diet and Lifestyle Recommendations) for competitive school foods (e.g., foods in vending machines) as part of its goal to reduce prevalence of childhood obesity; leading industry groups have signed on
American Medical Association
1979
Concepts of Nutrition and Health (Council on Scientific Affairs, 1979)
Moderate intake of salt to less than 12 g/d (4,800 mg/d sodium)
2006
Report of the Council on Science and Public Health (Dickinson and Havas, 2007; Havas et al., 2007)
Recommended a stepwise, minimum 50% reduction in sodium in processed foods, fast food products, and restaurant meals over the next decade; recommended that FDA revoke GRAS (generally recognized as safe) status of salt
American Dietetic Association
2007
Nutrition Fact Sheets and web page (www.eatright.org)
Provided sodium guidance on the meaning of sodium label claims and food purchasing or preparation techniques to reduce sodium intake
American Public Health Association
2002
Policy Statement: Reducing sodium content in the American diet (APHA, 2002)
Urged manufacturers to reduce the sodium content of processed foods by 50% over the next decade at a suggested rate of 5% per year
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American Institute for Cancer Research and World Cancer Research Fund
1997
Food, Nutrition, and the Prevention of Cancer: A Global Perspective (WCRF/AICR, 1997)
Limit salt from all sources to < 6 g/d
Adults
Limit consumption of salted foods and use of cooking and table salt
2007
Food, Nutrition, and the Prevention of Cancer: A Global Perspective (WCRF/AICR, 2007)
Limit consumption of salt
Population average consumption of salt from all sources to be < 5 g/d (2,000 mg/d sodium)
Proportion of the population consuming more than 6 g salt (2,400 mg sodium)/d should be halved every 10 years
World Action on Salt and Health
Annually since 2008
World Salt Awareness Week (World Action on Salt and Health, 2009)
The 2009 awareness week focused on the often high amount of hidden salt in foods obtained and consumed outside the home, and highlighted the importance of adding less salt to food and the longterm health implications of eating a high salt diet
World Hypertension League and World Action on Salt and Health
Annually since 2005
World Hypertension Day (World Hypertension League, 2009)
The 2009 day urged health experts and chefs to raise awareness of two “silent killers”: salt and high blood pressure
NOTE: d = day; g = gram; kcal = calorie; mg = milligram.
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